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MODERN OPHTHALMOLOGY 


BALL 





MODERN 


O PHTHALMOLOG Y 


A PRACTICAL TREATISE OR THE AH ATOMY, 
PHYSIOLOGIC AHD DISEASES 
OE THE EYE 


BY 

James Moobes Ball. M.D. 

Professor of Ophthalmology in the St. Louis College of Physicians and Surgeons 


SECOND EDITION 


With 417 Illustrations in the Text and Numerous 
Figures on 21 Colored Plates 



PHILADELPHIA 

F. A. DAVIS COMPANY 

1908 





A u 


(Library of congress 

j Two Copies Receive 

AHH 15 1908 

oeyyritfiH entry 


)\Mi A 


L- 


KXc, 

3 # 2 -/ 

COPY B. 


No. 


COPYRIGHT, 1904, 
COPYRIGHT, 1908, 

BY 

F. A. DAVIS COMPANY. 
[Registered at Stationers’ Hall, London, Eng.] 


Philadelphia. Pa., U. S. A. 
Press of F. A. Davis Company, 
1914-16 Cherry Street. 


Y*» 












DEDICATED 


TO 

HERMANN SNELLEN, Sr., 

OF UTRECHT, HOLLAND. 

AND 

CHARLES A. OLIVER, 

OF PHILADELPHIA, 

IN Recognition of their Valuable contributions 

TO 

MODERN OPHTHALMOLOGY. 




PREFACE. 


O 


In writing this hook it has been the authors aim to produce a work 
which shall teach, and which shall be valuable alike to the medical student, 
to the general practitioner, and to the specialist. The author hopes that 
he has succeeded in correctly representing the present advanced state of 
ophthalmic science and practice. 

Regarding the arrangement of subjects, the author’s experience as 
a teacher of ophthalmology has led him to believe in the advisability of 
combining embryology, anatomy, physiology, and diseases of the eye within 
one volume. In the clinical portion of the treatise congenital anomalies, 
tumors, inflammations and degenerations, injuries, and operations have 
been considered in the order mentioned. This is believed to be a logical 
sequence. 

The illustrations may possibly be worthy of mention. Many of them 
are original, and have been made either from the author’s dissections or 
from sections prepared under his direction. The colored pictures, illus¬ 
trative of external diseases and fundal conditions, are the handiwork of 
Miss Margaretta Washington, of Philadelphia. While some few have been 
made from sketches furnished by the author, the majority represent cases 
examined in the Wills Hospital of Philadelphia, to whose staff the author 
is under great obligations. The uncolored illustrations have been drawn 
chiefly by Drs. R. W. Mills and Carl Fisch, of St. Louis. The diagrams 
are the work of several individuals. 

Finding it to be impossible for him to finish the volume within the 
time-limit granted by the publisher, the author called several well-known 
ophthalmologists to his aid, all of whom responded courteously. Thus, 
the subject of “Anomalies of the Muscular Apparatus” was assigned to 
Dr. William Zentmayer; “Ocular Symptoms of Nervous Diseases,” to Dr. 
Jay C. Knipe; “Diseases of the Orbit,” to Dr. William T. Shoemaker; 

(vii) 



Vlll 


PREFACE. 


“Errors of Refraction,” to Dr. John T. Krall; “Hygiene of the Eyes,” to 
Dr. Harold G. Goldberg, all of Philadelphia, and “ Methods Employed in 
the Microscopic Examination of the Eye,” to Dr. W. E. Fischer, of St. 
Louis. Drs. Joseph Grindon and A. H. Ohmann-Dumesnil, of St. Louis, 
have given assistance in the preparation of that part of Chapter V which 
treats of the dermatologic diseases of the eyelids. 

The author desires to thank the F. A. Davis Company for the cour¬ 
teous treatment which he has received. The publishers have spared neither 
pains nor expense to make this book a worthy representative of its class. 

James Moores Ball. 

Saint Louis: 3509 Franklin Avenue. 


CONTENTS. 


CHAPTER I. 

Development of the Eye. 

Development of the eye—The lens—The vitreous humor—The secondary 
eye-cup and the eye-membranes—The optic nerve—Development of the retina 
—Accessory organs of the eye. 

CHAPTER II. 

Anatomy of the Eye. 

The Orbit—Foramina—Interorbital space—Orbital contents—The peri¬ 
osteum—The capsule of Tenon—The orbital muscles—Check ligaments— 
Nerves of the orbit—Blood-vessels of the orbit—The intermuscular cone of 
fat-—Position of the eyeball—The lacrimal apparatus—The eyelids—Blood¬ 
vessels, lymphatics, and nerves of the lids. Anatomy of the Eyeball—The 
fibrous coat (cornea)—Sclera—The vascular coat—Structure of the iris— 
The ciliary, body—The chorioid. The Optic Nerve, Retina, Lens, and 
Vitreous—The optic nerve-—The retina—Layers of the retina—Optic part of 
the retina—Cerebral layer—Neuroepithelial layer—Ciliary and iridal parts 
of the retina,—The optic commissure—Crossing of the optic fibres—Orbital 
portion of the optic nerve. Radiations of the Nerves of the Eye—Optic 
nerve—Oculomotor nerve—Patheticus nerve—Abducens nerve. The Crys¬ 
talline Lens—Dimensions of the lens—Structure of the lens—The lens-cap¬ 
sule—The zonula. The Vitreous Body. The Ocular Lymph-Spaces. The 
Normal Eundus Oculi—The optic disc—The blood-vessels—Perivascular 
lymph-channels—The macula lutea—The chorioid—The sclerotic. 

CHAPTER III. 

Physiology of Vision.*. 

Mechanism of the Formation of Images—Refraction—The reduced eye 
—The visual angle—The retinal image—Accommodation—Optical defects— 
Functions of the iris—Monocular diplopia. Ocular Movements and Binocu¬ 
lar Vision—Movements of the eye—Protrusion and retraction movements— 
Relative ocular movements—Blindness during ocular movements—Binocular 
single vision—Stereoscopic vision. Functions of the Retina—The field of 
vision—The blind spot—The macula lutea—Direct and indirect vision—The 
rods and cones in vision—Optograms—Duration of visual sensations—Irradi¬ 
ation—Relation of sensation to the intensity of the stimulus—Time neces¬ 
sary for excitation of the retina by light—Clearness of vision—Inversion of 
the image—The visual centre—Color-perception—Normal variation in color- 
perception—Theories of color-perception. The Oculai Adnexa. 

CHAPTER IV. 

Examination of the Ey'E. 

The case-history. External Examination—Eyelids—Eversion of the lids 
—Ocular conjunctiva—Lacrimal apparatus—The caruncle—The sclerotic— 
The length of the eye—The cornea—The anterior chamber—The iris—The 

(ix) 







X 


CONTENTS. 


PAGE 

pupil—The pupillary area—The crystalline lens—The vitreous humor—The 
ciliary body—The tension of the eye—The orbit—Balance of the ocular 
muscles—Power of the ocular muscles—Strabismometry—Keratometry— 
Testing visual acuity—Examination of near vision—Measurement of con¬ 
vergence—Perimetry—Defects in the visual field—Testing the light-sense— 
Testing the color-sense—The use of mydriatics—The use of miotics. Oph¬ 
thalmoscopy—Description of the ophthalmoscope—Methods of use—The 
room and light—Position of examiner and patient—Size of the ophthalmo¬ 
scopic image—Uses of the ophthalmoscope—The fundus-reflex test—Tests 
for simulated blindness—Localization of foreign bodies. 

CHAPTER V. 

Diseases of the Eyelids. 158 

Congenital Anomalies of the Eyelids—Ablepharia—Coloboma of the lids 
■— Cryptophthalmos — Symblepharon — Ankyloblepharon — Blepharophi- 
mosis — Microblepharon — Entropion — Ectropion — Distichiasis — Epi- 
cantlius—Congenital ptosis—Fistula of the upper lid—Treatment of con¬ 
genital anomalies. Skin Diseases of the Lids—Erythemata—Urticaria— 
Eczema of the eyelids—Fissures of the external canthus—Impetigo—Fu¬ 
runcle—Frambesia—Furunculus orient alis—Malignant pustule—Carbuncle 
—Abscess of the lid—Tarsitis—Erysipelas—Herpes zoster ophthalmicus— 
Pemphigus—Lichen—Dermatitis—Blastomycetic dermatitis—Perifolliculitis 
— Congenital hyperkeratosis — Chloasma-—Discoloration of the eyelids — 
Dermoid tumors-—-Verruca — Cornu cutaneum — Lipoma — Hernia of the 
orbital fatty tissue — Edema of the lids — Solid edema of the lids — Ele¬ 
phantiasis Arabum—Lentigo—Varicose veins—Nsevus pigmentosus—Vitiligo 
-—Xeroderma pigmentosum—Keratosis follicularis—Molluscum epitheliale— 
Xanthoma—Lupus erythematosus—Tuberculosis—Lupus vulgaris—Syphilis 
—Leprosy—Keloid—Plexiform neuroma of the eyelid—Fibroma of the eye¬ 
lid—Nsevus vasculosus—Lymphoma of the eyelids—Carcinoma of the lid— 
Epithelioma—Rodent ulcer—Sarcoma of the eyelid—Adenoma of the Meibo¬ 
mian glands—Noma of the eyelids—Colloid degeneration of the skin—Hy- 
peridrosis—Chromidrosis—Phosphoridrosis and uridrosis—Sudauiina—Sebor¬ 
rhea—Miliaria—Milium—Acne rosacea—Asteatosis—Steatoma—Chalazion— 
Alopecia—Parasitic skin diseases—Favus of the eyelids—Cysticercus of the 
eyelid—Variola—Vaccinia of the eyelid—Varicella-—Scarlatina—Rubeola— 
Blepharoelialasis—Emphysema of the eyelids—Blepharitis marginalis. Other 
Diseases of the Eyelids—Lagophthalmos—Blepharophimosis—Blepharo¬ 
spasm — Trichiasis and distichiasis — Symblepharon — Ankyloblepharon -— 
Ptosis-—Ectropion—Entropion. Injuries of the Eyelids—Wounds of the lids 
—Burns and scalds of the eyelids—Foreign bodies in the eyelids. Opera¬ 
tions on the Eyelids—Chalazion operations—Operations for ptosis—Tarsor¬ 
rhaphy—Canthoplasty—'Trichiasis operations—Entropion operations—Epi- 
canthus operations—Ectropion operations—Blepharoplastie operations— 
Blepharoplasty without a pedicle. 

CHAPTER VI. 

Diseases of the Lackimal Apparatus. 219 

Diseases of the Lacrimal Gland—Inflammation of the lacrimal gland— 
Dacryoadenalgia—Simple hypertrophy or adenoma of the lacrimal gland— 
Atrophy of the gland—Dacryoliths—Dacryops—Hydatid cyst—Fistula of 
the lacrimal gland—Dislocation of the gland-—Syphilis of the lacrimal gland 
—Tumors of the lacrimal gland—Affections of the accessory glands. Dis- 




CONTENTS. 


Xi 


PAGE 

eases of the Drainage Apparatus—The puncta—The eanaliculi—Leptothrix 
lacrimalis—Lacrimal actinomycosis—Inflammation of the lacrimal sac— 
Catarrhal dacryocystitis—Suppurative dacryocystitis—Obstruction and stric¬ 
ture of the lacrimo-nasal duct—Fistula of the lacrimal sac. Lacrimal 
Operations. 

CHAPTER VII. 

Diseases of the Conjunctiva. 239 

Congenital Anomalies. Tumors of the Conjunctiva—Dermoid tumor— 
Subconjunctival lipoma—Fibroma—Polypi, papillomata, and granulation 
tumors — Vascular tumors — Osteoma — Cysts — Lymphectasise — Sarcoma 
—Epithelioma. Inflammations of the Conjunctiva—Conjunctival injection— 
Hyperemia of the conjunctiva—Conjunctivitis—Simple conjunctivitis—Acute 
contagious conjunctivitis—Subacute catarrhal conjunctivitis—Chronic catar¬ 
rhal conjunctivitis—Follicular conjunctivitis—Drug conjunctivitis—Vernal 
conjunctivitis—Purulent conjunctivitis—Gonorrheal ophthalmia of the adult 
—Ophthalmoblennorrhea neonatorum-—Non-gonorrheal purulent conjuncti¬ 
vitis — Croupous conjunctivitis — Diphtheritic conjunctivitis — Phlyctenular 
conjunctivitis — Herpes of the conjunctiva — Papular conjunctivitis — Pem¬ 
phigus of the conjunctiva—Parinaud’s conjunctivitis—Lithiasis of the con¬ 
junctiva—Egyptian and military conjunctivitis—-Variolar conjunctivitis— 
Chronic conjunctivitis-—Lacrimal conjunctivitis—Granular conjunctivitis— 
Vaccinia of the conjunctiva-—Varicella of the conjunctiva—Conjunctivitis 
petrificans. Miscellaneous Diseases of the Conjunctiva —- Ophthalmia no¬ 
dosa—Filaria—Pterygium—Pseudo pterygium—Pinguecula—Amyloid degen¬ 
eration of the conjunctiva—Xerosis—Tuberculosis of the conjunctiva— 
Argyrosis of the conjunctiva—Leprosy—Lupus of the conjunctiva—Hemor¬ 
rhage from the conjunctiva—Abscess of the conjunctiva—Actinomycosis of 
* the conjunctiva—Syphilis of the conjunctiva—Conjunctival ulcers—Subcon¬ 
junctival eecliymosis-—Emphysema of the conjunctiva—Chemosis—Sym- 
blepharon. Injuries to the Conjunctiva—Foreign bodies—Burns of the 
conjunctiva. Affections of the Caruncle—The plica semilunaris and caruncle 
—Tumors of the caruncle. Operations on the Conjunctiva—Pterygium opera¬ 
tions—Symblepharon operations—Skin-grafting in symblepharon—Removal 
of tarsus and retr-otarsal folds-—Excision of the upper cul-de-sac —Expression 
of the contents of trachoma follicles—Grattage of the conjunctiva—Periec- 
tomy-—Peritomy—Subconjunctival injections. 

CHAPTER VIII. 

Diseases of the Cornea. 303 

Congenital Anomalies—Opacities—Pigmentation—Congenital ectasia— 
Hydrophtlialmos — Megalocornea and keratoglobus —- Megalophthalmos. 

Tumors of the Cornea. Classification of Corneal Inflammations. Suppura¬ 
tive Keratitis—Ulcer of the cornea—Creeping ulcer of the cornea—Treat¬ 
ment of corneal ulcers—Neuroparalytic keratitis—Lagophthalmic keratitis— 
Xerophthalmic keratomalacia. Non-suppurative Keratitis — Phlyctenular 
keratitis—Interstitial keratitis—Vascular keratitis—Keratitis bullosa—Asper- 
gillar keratitis—Malarial keratitis—Filamentary keratitis—Keratitis punc- 
- tata-—Superficial punctate keratitis—Ribbon-shaped corneal opacity—Herpes 
of the cornea—Marginal keratitis—Striped keratitis—Disc-like keratitis— 
Grill-like keratitis. Miscellaneous Diseases of the Cornea—Discoloration 
of the cornea with blood-pigment—Sclerosis and atrophy of the limbus— 
Siderosis of the cornea—Xanthelasma of the cornea—Tuberculosis of the 
cornea—Lepra of the cornea. Protrusions of the Cornea—Staphyloma of 




xn 


CONTENTS. 


PAGE 

the cornea — Keratocpnus — Keratoglobus — Keratectasia — Fistula of the 
cornea. Opacities of the Cornea—Arcus senilis—Opacities due to keratitis. 
Injuries of the Cornea—Mechanical injuries of the cornea—Healing of 
corneal wounds—Hemorrhage into the cornea—Foreign bodies in the cornea. 
Operations on the Cornea—Abrasion of the cornea—Paracentesis of the 
cornea—Cauterization of the cornea—Excision of the cornea—Keratotomy— 
Operation for fistula of the cornea—Temporary renversemcnt of a corneal 
flap—Tattooing of the cornea—Keratoplasty. 

CHAPTER IX. 

Diseases of the Sclera. 3G1 

Congenital Anomalies. Tumors of the Sclera. Inflammations of the 
Sclera—Episcleritis—Fugacious episcleritis—Scleritis. Protrusions of the 
Sclera. Injuries of the Sclera. 

CHAPTER X. 

Diseases of the Iris. 374 

Congenital Anomalies—Coloboma of the iris—Persistent pupillary mem¬ 
brane—Corectopia—Polycoria—Aniridia—Heterochromia—Exfoliation of the 
iris—Melanoma-—Ectropion of the uvea—Albinism—Congenital tumors of 
the iris—Congenital atrophy of the iris—Adhesion of the iris to the cornea. 
Tumors of the Iris—Cysts of the iris—Sarcoma of the iris—Vascular tumors 
of the iris—Unusual tumors of the iris—Leprosy of the iris—Tubercle of the 
iris-—Cysticercus—Filaria. Inflammation of the Iris—Iritis—Varieties of 
iritis—Uveite. Injuries of the Iris—Iridodialysis-—Anteversion of the iris 
—Laceration of the sphincter of the iris—Inversion of the iris—Traumatic 
irideremia—Prolapse of the iris—Foreign bodies. Motor Disturbances of 
the Iris—Mydriasis, miosis-—Hippus-—Iridodonesis. Changes in the Anterior 
Chamber—Depth—Contents. Operations on the Iris—Iridectomy—Trans¬ 
fixion of the iris-w-Iridenkleisis—Iridocapsulotomy—Iridocystectomy. 

CHAPTER XI. 

Diseases of the Ciliary Rody.. 404 

Coloboma of the ciliary body-—Tumors of the ciliary body—Gumma of 
the ciliary body-—Serous cyclitis—Plastic cyclitis-—Purulent cyclitis—In¬ 
juries of the ciliary body. 

CHAPTER XII. 

Diseases of the Ciiorioid. 411 

Congenital Anomalies—Coloboma of the chorioid and retina—Albinism. 
Tuberculosis of the Chorioid—Tubercles of the chorioid—Large tubercular 
mass. Tumors of the Chorioid—Carcinoma of the chorioid—Other tumors 
of the chorioid—Sarcoma of the chorioid—Myoma of the chorioid—Ossifica¬ 
tion of the chorioid. Inflammation of the Chorioid—Hyperemia of the 
chorioid—Exudative chorioiditis—Purulent chorioiditis. Injuries of the 
Chorioid—Wounds of the chorioid-—Foreign bodies—Chorioidal hemorrhage 
—Detachment of the chorioid—Rupture of the chorioid—Colloid disease of 
the macular region—Atrophy of the eyeball—Phthisis bulbi—Ophthal¬ 
momalacia. 

CHAPTER XIII. 

Diseases of the Crystalline Lens. 437 

Congenital Anomalies—Coloboma of the lens—Microphakia—Lenticonus 
—Congenital aphakia-—Congenital luxation of the lens. Cataract—Senile 
cataract—Congenital cataract—Soft cataract—Traumatic cataract—Second¬ 
ary cataract—Complicated cataract—Diabetic cataract. Operations for 







CONTENTS. 


Xlll 


PAGE 

Cataract—Preparation of the patient—Choice of an anesthetic—Extraction 
of senile cataract—Accidents during and following the operation—Peculiari¬ 
ties in the healing process—Choice of cataract extractions—Preliminary iri¬ 
dectomy—Should both eyes be operated on at the same sitting?—Other 
methods of extraction—Extraction of immature cataract—Scleronyxis—Oper¬ 
ations for juvenile cataract—Operations for traumatic cataract—Procedures 
for post-operative cataract—Artificial ripening of cataract—Operations for 
artificial ripening—Refraction after extraction—Results of cataract opera¬ 
tions—Spontaneous cure of cataract. Dislocation of the Lent, etc.—Ac¬ 
quired dislocation of the lens—Parasites in the lens—Spontaneous extrusion 
of the lens-—Ossification of the lens—Regeneration of the lens—Injuries of 
the lens—Foreign bodies in the lens. 

CHAPTER XIV. 

Diseases of the Vitreous Humor. 473 

Coloboma of the vitreous humor—Persistent hyaloid artery—Inflamma¬ 
tion of the vitreous humor—Suppurative hyalitis—Opacities of the vitreous 
humor—Hemorrhage into the vitreous humor-—Fluidity of the vitreous— 
Svnehysis scintillans—Animal parasites in the vitreous humor—Formation 
of new vessels in the vitreous—Pseudo-neuroepithelioma—Foreign bodies in 
the vitreous—Detachment of the vitreous—Retinitis proliferans. 

CHAPTER XV. 

Diseases of the Retina.:. 481 

Congenital Anomalies. Tumors of the Retina—Retinal cysts—Neuro¬ 
epithelioma. Parasites—Subretinal cysticercus—Subretinal echinococcus. 
Retinal Changes from Circulatory Disturbances—Anemia of the retina— 
Ischemia of the retina—Hyperemia of the retina—Retinal vasculitis and 
perivasculitis—Aneurism of the retinal vessels—Apoplexy of the retina— 
Subhyaloid hemorrhage—Embolism of the central retinal artery—Throm¬ 
bosis of the central retinal artery—Thrombosis of the central retinal vein. 
Inflammation of the Retina—Simple, or serous, retinitis—Syphilitic retinitis 
—Parenchymatous retinitis—Leucocythemic retinitis—Diabetic retinitis—Al¬ 
buminuric retinitis—Gouty retinitis—Symmetrical macular changes in in¬ 
fancy—Retinitis circinata—Retinitis from exposure to excessive light—Punc¬ 
tate conditions of the fundus—Purulent retinitis—Purulent traumatic reti¬ 
nitis—Purulent secondary retinitis—Purulent metastatic, or embolic, retinitis 
—Septic retinitis. Retinal Scleroses—Retinitis proliferans—Striate retinitis 
—Pigment-streaks on the fundus—Pigmentary degeneration of the retina. 
Injuries of the Retina—Traumatic retinitis—Retinal hemorrhage from 
trauma—Traumatic detachment of the retina—Rupture of the retina—Pig¬ 
mentation of the retina following trauma—-Traumatic anesthesia of the 
retina—Traumatic perforations of the macula lutea. Detachment of the 
Retina. Functional Diseases of the Retina—Hyperesthesia of the retina— 
Anesthesia of the retina—Tuberculosis of the retina. 

CHAPTER XVI. 

Diseases of the Optic Nerve. 528 

Congenital Anomalies—Absence of the optic nerve—Atrophy of the 
nerve—Coloboma of the optic nerve—Congenital cupping and other condi¬ 
tions of the disc. Tumors—Primary intradural tumors of the optic nerve— 
Primary extradural tumors of the optic nerve—Hyalin bodies in the nerve- 
head. Inflammation of the Optic Nerve—Intra-ocular optic neuritis—Retro¬ 
bulbar optic neuritis—Optic neuritis with nasal discharge—Spurious optic 





XIV 


CONTENTS. 


* PAGE 

neuritis. Toxic Amblyopias—Toxic amblyopia—Quinin-amaurosis—Methyl- 
alcohol amblyopia—Ptomain poisoning. Atrophy of the Optic Nerve—Pri¬ 
mary optic-nerve atrophy—Secondary optic-nerve atrophy—Retinal type of 
optic-nerve atrophy—Embolic atrophy—Hereditary optic-nerve atrophy— 
Hemorrhage into the sheath of the optic nerve. Disturbances of Vision 
without apparent Lesion—Congenital amblyopia—Acute amaurosis follow¬ 
ing infantile convulsions—Congenital amblyopia for colors—Amblyopia ex 
anopsia—Uremic amaurosis—Diabetic amaurosis—Amblyopia from hemor¬ 
rhage-—Simulated amblyopia—Nyctalopia—Hemeralopia—Scotoma scintil- 
lans—Snow-blindness—Hemianopsia—Reflex amblyopia—Hysteric amblyopia 
—Colored vision—Malarial amblyopia—Micropsia, megalopsia, and metamor- 
phopsia. Injuries of the Optic Nerve. Operations on the Optic Nerve—- 
Opticociliary neurotomy—Opticociliary neurectomy—Value of these pro¬ 
cedures. 

CHAPTER XVII. 

Glaucoma . 562 

Normal intra-ocular tension—Glaucoma: general considerations—Clin¬ 
ical varieties and treatment of primary glaucoma—Glaucoma simplex— 
Chronic irritative glaucoma—Acute inflammatory glaucoma—Hemorrhagic 
glaucoma—Glaucoma absolutum—Treatment of the apparently unaffected 
eye in glaucoma—Glaucoma after cataract operation—Prevention of primary 
glaucoma—Hydrophthalmos—Secondary glaucoma—Hypotony—Operations 
for glaucoma—Iridectomy—Iridectomy in the aphakic eye—Sympatheticec- 
tomy—Large paracentesis of the sclerotic with cyclicotomy—Sclerotomy. - 

CHAPTER XVIII. 

Sympathetic Eye Diseases: Indications for Enucleation. 594 

Sympathetic irritation—Sympathetic ophthalmitis—Indications for enu¬ 
cleation—Enucleation and its substitutes—Technique of evisceration—Evis¬ 
ceration with insertion of an artificial vitreous—Sclero-optic neurectomy— 
Implantation of a sphere into Tenon’s capsule—Immunity to sympathetic 
ophthalmitis—Advantages of Mules’s operation versus enucleation—Ocular 
prosthesis—Operation for the better support of an artificial eye—Operations 
for prosthesis in cicatricial orbit. 

CHAPTER XIX. 

Diseases of the Orbit. 616 

Congenital Anomalies—Cyclopia—The orbital contents—Anophthalmos 
—The ocular muscles—Congenital cysts of the orbit—Meningocele and en- 
cephalocele. Tumors of the Orbit—Etiology and location—Innocence or 
malignancy — Varieties of tumors -—• Lipoma —- Angioma — Lymphangioma 
—Chondroma—Sarcoma—Osteoma—Plexiform neuroma—Epithelial tumors 
—Cysts of the orbit. Inflammations of the Orbit—Periostitis—Periostosis 
—Hyperostosis—Exostosis—Orbital cellulitis and phlegmon—Inflammation of 
the oculo-orbital fascia—Diseases of the frontal, ethmoidal, maxillary, and 
sphenoidal sinuses—Cavernous-sinus thrombosis—Hemorrhage into the orbit 
—Pulsating exophthalmos—Intermittent exophthalmos—Enophthalmos— 
Exophthalmic goitre. Wounds and Injuries of the Orbit—Contusion—In¬ 
juries to the orbital margin—Wounds of the soft tissues of the orbit—Lux¬ 
ation and avulsion of the globe—Fracture of the orbital bones—Foreign 
bodies in the orbit. Operations on the Orbit—Removal of tumors—Kron- 
lein’s operation—Exenteration of the orbit. 





CONTENTS. 


XV 


CHAPTER XX. p vGE 

Anomalies of the Muscular Apparatus . 654 

Action of the muscles—Binocular movements—General symptomatology 
—Special symptomatology—Cerebral lesions—Nuclear palsies—Ophthalmo¬ 
plegia—Prognosis of ocular paralyses—Paralytic mydriasis—Paralytic miosis 
—Paralysis of accommodation—Spastic strabismus—Nystagmus—-Deviation 
of the visual axes of non-paralytic origin—Determination of the angle of 
squint-—Latent deviation—Operations on the ocular muscles. 

CHAPTER XXI. 

Errors of Refraction .. 6S6 

Properties of Optical Lenses—Light—Refraction—Convex and concave 
lenses—Numbering of lenses. Emmetropia. Ametropia. Hypermetropia— 
Definition — Etiology — Pathology -— Symptoms -— Diagnosis — Treatment. 
Myopia — Definition — Etiology — Pathology — Symptoms — Diagnosis — 
Treatment. Astigmatism — Definition — Varieties — Etiology — Symptoms 
—Treatment. Aphakia — Definition — Etiology — Symptoms — Diagnosis — 
Treatment. Presbyopia — Definition — Etiology — Diagnosis — Treatment. 
Antimetropia and Anisometropia—Definition—Etiology—Diagnosis—Treat¬ 
ment. 

CHAPTER XXII. 

The Ocular Manifestations of Nervous Diseases. 733 

General Considerations—Conjugate lateral paralysis—-Ptosis—Various 
paralyses—Nystagmus. Conditions of the Pupil—-Miosis—Mydriasis. The 
Visual Tract. The Eield of Vision—Hemianopsia. Focal Lesions of the 
Brain—Optic neuritis—Hemianopsia—Hemianoptic pupil-symptom of Wer¬ 
nicke—Visual amnesia—Alexia—Visual aphasia—Dyslexia—Amnesic color¬ 
blindness—Visual hallucinations. Ocular Symptoms of Organic Diseases 
of the Brain and Spinal Cord—Ocular symptoms of meningitis—Multiple 
sclerosis—Locomotor ataxia—Pseudobulbar paralysis of cerebral origin— 
Combined sclerosis of the spinal cord—Friedreich’s ataxia—Acute ascend¬ 
ing paralysis — Myelitis—Multiple neuritis—Migraine—Neuralgia—Herpes 
• zoster—General paralysis of the insane—Insanity—Paralysis agitans—Infan¬ 
tile paralysis—Tetany—Hydrocephalus—Acromegalia—Thomsen’s disease 
—Syringomyelia and Morvan’s disease—Epilepsy—Chorea—Exophthalmic 
goitre. Asthenopia, Amblyopia, and Amaurosis of Nervous Origin— 
Neurasthenia — Hysteria — Neurosis following traumatism. Other Forms 
of Amblyopia and Amaurosis — Amblyopia caused by a disturbance of 
the cerebral circulation—Reflex amblyopia—Congenital amblyopia—Pre¬ 
tended amblyopia and amaurosis—Tests for binocular blindness—Tests for 
non-ocular amblyopia—Erythropsia. 

CHAPTER XXIII. 

Preparation for Ophthalmic Operations. 749 

Qualifications of the surgeon—Preparation of the surgeon and assistants 
—Preliminary preparation of the patient—Time for operation—Preparation 
of the region of operation—Assistants—Preparation of the instruments— 
Preparation of mops and dressings—Local hemostasis—The operation room. 

CHAPTER XXIV. 

The Hygiene of the Eyes. 

Care of the Eyes at Birth, during Infancy, and in early Childhood— 
Kindergartens—Light—Print—Reading. Care of the Eyes during School- 


756 







xvi 


CONTENTS. 


PAGE 

life—Construction of school-buildings in relation to hygiene—Prevalence of 
myopia in the public schools. The Influence of Injurious Habits on the 
Eyes of Adults—The effect of occupation upon the' eyes—Care of the eyes 
during epidemics. Care of the Eyes in Old Age—Climatic changes in their 
effects upon the eyes—Care of spectacles. 

CHAPTER XXV. 

Methods Employed in the Micboscopic Examination of the Eye. 772 

Material—Preservation of eyeballs for demonstration—Fixing—Washing 
—Decalcification—Bleaching—Hardening—Cutting the eyeball preparatory 
to mounting—Imbedding—Cutting the sections—Staining—Nuclear stains— 
Protoplasmic stains—Dehydration of the sections—Clearing of the sections— 
Mounting the sections on slides—Demonstration of definite substances and 
tissue-elements—Demonstration of foreign substances in the eye—Staining 
for bacteria in sections. 

Index . 793 




LIST OF ILLUSTRATIONS. 


FIG. PAGE 

L Transverse section through the brain of a chick: three days’ incubation. (Author.). 1 

2. The secondary eye-vesicle, with lens-fossette. (After VON Kolliker.) . 2 

3. Constriction of the lens. (After Van Bambeke.) . 2 

4. The eye-stalk and the eye. (Koiamann.) . 3 

5. Tunica vasculosa lentis. (After O. Schultze.) . 4 

6. Scheme of the secondary eye-vesicle. (Manz-Ziegler.) . 5 

7. Vertical section of the anterior half of an eye from a human embryo of eight or nine 

weeks. (After von Kolliker.) . 5 

8. Section of two ciliary processes of a human embryo, enlarged 200 diameters. (After 

Krischewski.) . 8 

9. Eye of a human embryo of seven weeks, enlarged 20 diameters. (Kollmann.) . 8 

10. Inner wall of the orbit and adjacent parts. (His.) . 8 

11. Frontal section showing the relation of the orbits to the other cavities of the skull. 

(After ZUCKERKANDL.) . 10 

12. Capsule of Tenon. (Merkel.) . 11 

13. Horizontal section of the right orbit, viewed from above. (After Gerlach.) . 12 

14. Position of eyeball in the right orbit and the location of the orbital muscles. 

(Merkel.) . 13 

15. The right orbit opened from behind. (Author.) . 14 

16. Sagittal section of the orbit. (After Deaver.) . 15 

17. Dissection of base of left orbit. (Author.) . 16 

18. Distribution of the third and sixth nerves in the orbit. (Leveille.) . 16 

19. Ophthalmic division of the fifth nerve. (Leveille.) . 17 

20. Lateral view of the orbit, showing the nerves. (After Deaver.) . 18 

21. The ophthalmic artery and its branches, viewed from above. (After Merkel and 

Kallius.) . 20 

22. Distribution of the ophthalmic vein. (Gurwitsch.) . 21 

23. The nasal duct and lacrimal gland. (Author.) . 23 

24. Probes introduced into the canaliculi to show their direction. (Author.) . 24 

25. Section of the upper eyelid. (Author.) . 25 

26. Arteries of the (right) eyelids. (Author.) . 27 

27. Veins of the (left) eyelids. (After Soemmering.) . 28 

28. Antero-posterior section of the eyeball. (Leveille.) . 29 

29. Section through the human cornea. (Bohm and Davidoff.) . 30 

30. Corneal corpuscles of the dog. (Bohm and Davidoff.) . 31 

31. The iridocorneal angle. (Author.) . 32 

32. Corneal nerves of the pig. (After Rollett.) . 33 

33. Radial section of the human iris. (Author.) . 34 

34. Diagram of the vessels of the eye. (Leber.) . 35 

35. Injected blood-vessels of the iris, ciliary body, and chorioid of man. X 7. Bohm and 

Davidoff.) . 36 

36. Meridional section of the human ciliary body. (After Bohm and Davidoff.) . 37 

37. Meridional section of human ciliary processes. (Piersol.) . 38 

38. Section through the ciliary region of an hypermetropic eye. (Iwanoff.) . 39 

39. Section through the ciliary region of a myopic eye. (Iwanoff.) . 39 

40. Bleached section showing glands of the ciliary body. X 300. (Treacher Collins.).. 40 

41. Vertical section of the chorioid. (Bohm and Davidoff.) . 40 

42. Diagram of occipital region of right cerebral hemispheres . 42 

43. The macula near the fovea centralis. X 80 . 43 

44. Hexagonal cells from the pigment layer of the retina of a rabbit. (Author.) . 44 

45. Diagram of the structure of the human retina according to Golgi's method. (Greeff.) 45 

46. Photomicrograph of the optic chiasma, showing decussation of the nerve-fibres. 

(Author.) . 48 

47. Transverse section of orbital part of the optic nerve behind the entrance of the central 

vessels. (After Merkel.) . 49 

48. Transverse section of the orbital part of the optic nerve in front of the entrance of 

the central vessels. (After Merkel.) . 50 

49. Isolated lens-fibres. (After J. Arnold.) . 52 

50. Transverse section of lens-fibres. (After J. Arnold.) . 52 

51. Anterior surface of the lens of an adult. (After J. Arnold.) . 53 

52. Marginal whorl of the lens, showing the transition of the epithelium into lens-fibres. 

(Schultze.) . 53 

53. Epithelium of the inner surface of the anterior capsule. (Schultze.) . 54 

54. Dissection to show the zonula. (After Schultze.) . 55 

55. Diagram of lymph-spaces of the eyeball. (After Fuchs.) . 56 

56. The normal fundus of the right eye. (Henle.) . 57 

57. Diagram of the retinal vessels of the left eye. 5S 

58. Injected blood-vessels of the macular region. (Bohm and Davidoff.) . 59 

59. Diagram of a simple optical system . 62 

60. Action of a biconvex lens upon rays of light . 63 

61. Action of a convex lens on rays of light proceeding from a point within the focus...... 63 

62. The image formed by a biconvex lens . 64 

(xvii) 






























































LIST OF ILLUSTRATIONS. 


xviii 

FIG. PAGE 

63. Diagram of the reduced eye ... 65 

64. Diagram to show that the visual angle and size of the retinal image vary with the 

distance of the object from the eye . 66 

65. Purkinje-Sanson images . 67 

66. Diagram showing the corneal axis, the optic axis, the visual line, the line of fixation, 

and the three angles . 68 

67. Diagram to show spheric aberration . 6.8 

68. Diagram to show chromatic aberration . 69 

69. Diagram to show the primary position of the right eye, the eye turned upward and 

inward, and downward and outward . 74 

70. The horopteric circle of Joannes Muller . 76 

71. Diagram of the field of binocular vision . 77 

72. Diagram of the normal visual field for white and colors. (Jennings.) . 78 

73. Diagram to show the blind spot in the visual field .. 79 

74. Diagram to show irradiation . 81 

75. Diagram of the decomposition of solar light into the spectral colors. (Jennings.) - S2 

76. Eversion of the upper eyelid . 88 

77. Examination of the eye of a child . 89 

78. Noyes’s retractor . 90 

79. Position for secondary eversion of the upper lid . 90 

80. Diagram to show the vascular systems of the eye . 91 

81. Diagram to show focal (or oblique) illumination . 93 

82. Placido’s disc . 94 

83. Jackson’s binocular magnifier . 95 

84. Opacities in the lens . 99 

85. Method of taking the tension of the eye . 100 

86. The Maddox rod . 102 

87. Diagram to show the Maddox rod test for horizontal deviations. 103 

88. Diagram to show the Maddox rod test for vertical deviations . 103 

89. The von Graefe test, used at the reading distance . 104 

90. The Maddox double prism as a near test . 104 

91. Use of the Maddox double prism for far . 105 

92. Diagram to show use of the Maddox double prism for near . 106 

93. Diagram to show the use of the Maddox double prism in testing the oblique muscles... 107 

94. Stevens’s improved rotating prism slide .«... 107 

95. Stevens’s phorometer ready for use . 108 

96. Risley’s rotary prism . 108 

87. Prism-holder. (Noyes.) . 109 

98. Prism-holder. (Helen.) . 110 

99. Tropometer. (Stevens.) . Ill 

100. Scale of the tropometer . 112 

101. Measurement of strabismus by the perimeter . 113 

102. Measurement of convergent strabismus of right eye by Priestley Smith’s method. 114 

103. Strabismometer . 116 

104. Linear measurement of strabismus . 116 

105. Schematic section of the Kagenaar model of the Javal-Schioetz ophthalmometer. 

(Kagenaar.) . 117 

106. Appearance of the mires in the primary position. (Kagenaar.) . 118 

107. Appearance of the mires in the secondary position, showing four dioptres of astig¬ 

matism. (Kagenaar.) . 118 

108. The visual angle . 119 

109. Snellen’s test-type . 119 

110. Wallace’s test-type . 119 

111. Improved trial-frame . 120 

112. The hair-optometer .122 

113. Measurement of the near point . 123 

114. The McHardy perimeter . 125 

115. Forster’s photometer. (Fick.) . 128 

116. Wools for the detection of color-blinduess. (Oliver.) . 130 

117. Color-sense measure. (Oliver.) . 131 

118. Morton’s ophthalmoscope . 135 

119. Loring’s ophthalmoscope . 136 

120. Direct ophthalmoscopy . 137 

121. Indirect ophthalmoscopy . 137 

122. Relative positions in direct ophthalmoscopy . 138 

123. Indirect ophthalmoscopy . 139 

124. Localization of opacities in the lens and cornea. (Fick.) . 140 

125. Ophthalmoscopy in emmetropia . 142 

126. Measurement of hypermetropia by direct ophthalmoscopy . 142 

127. Measurement of hypometropia (myopia) by direct ophthalmoscopy . 143 

128. Diagram to show parallactic displacement in indirect ophthalmoscopy . 144 

129. Diagram to explain retinoscopy with the concave mirror. (After Landolt.) . 145 

130. Retinoscopy mirror . 147 

131. Thorington’s light-screen with iris-diaphragm . 148 

132. Movement of the shadow in myopia . 148 

133. Movement of the shadow in emmetropia, low myopia, and hypermetropia . 149 

134. Movement of the shadow in mixed astigmatism . 150 

135. Diagram to show correction of astigmatism . 151 

136. Thorington’s axonometer . 151 

137. Test for simulated blindness. (Fridenberg.) . 153 

138. Apparatus for fixing the head in x-ray examination. (Davidson.) . 155 

139. The crossthread localizer. (Davidson.) . 156 

140. Herpes zoster ophthalmicus. (Fuchs.) .,.... 164 

141. Blastomycetic dermatitis involving the eyelids. (Walker.) . 166 

142. Dermoid tumor. (Author.) . 168 

143. Verruca of the eyelids. (Von Ammon.) . 169 

144. Cornu cutaneum. (Schaw.) . 169 

145. Solid edema of the eyelids. (Critchett.) . 170 



















































































LIST OF IT,LUSTRATIONS. x [ x 


FIG - PAGE 

146. Elephantiasis of the upper eyelid. (After Walzberg.) . 171 

147. Varicose vein of the upper eyelid. (Author.) . 171 

148. Gummata of the eyelids. (Keber.) . 174 

149. Microscopic section of an epithelioma of the eyelid. (Author.) . 176 

160. Rodent ulcer. (Grindon.) . 178 

151. Microscopic section of a chalazion. (Author.) . 1S1 

152. Varioloid of the eyelids. (Von Ammon.) . 183 

153. Cicatricial ectropion. (Author.) . 192 

154. Burn of face and eyelids. (Vail.) . 194 

155. Result of burn of face and eyelids. (Vail.) . 195 

156. Entropion forceps. (Author.) . 196 

157. Wilder’s operation for ptosis . 197 

158. Incisions and sutures in Panas’s operation . 198 

159. Appearance of the eye after Panas’s operation . 199 

160. Operation for ptosis. (Tansley.) . 199 

161. Tarsorrhaphy by von Graefe’s method. (Czermak.) . 200 

162. Tarsorrhaphy by Fuchs’s method. (Czermak.) . 200 

163. Von Ammon’s canthoplasty. (After Czermak.) . 201 

164. The sutures in place in canthoplasty. (After Czermak.) . 201 

165. Excision operation for trichiasis. (After Stephenson.) . 202 

166. Jaesche-Arlt operation for trichiasis . 203 

167. Section of the upper eyelid in Snellen’s operation for entropion . 204 

168. The method of placing the sutures in Snellen’s operation for entropion. 204 

169. Hotz’s operation tor entropion . 205 

170. Harlan’s operation for entropion . 205 

171. Von Ammon’s operation for epicanthus . 206 

172. Wicherkiewicz’s operation for epicanthus . 207 

173. Snellen’s thread operation for ectropion . 207 

174. Von Langenbeck’s operation for ectropion . 208 

175. Von Ammon’s operation for ectropion . 209 

176. Dieffenbach’s operation for ectropion . 209 

177. Sanson’s operation for ectropion . 209 

178. Robertson’s first operation for ectropion . 210 

179. Robertson’s latest operation for ectropion . 210 

180. Kuhnt’s operation for ectropion . 211 

181. Supporting stitch in Kuhnt’s operation . 211 

182. Miiller’s ectropion operation . 212 

183. Hotz’s operation for cicatricial ectropion of the lower eyelid . 212 

184. Hotz’s operation for cicatricial ectropion of the upper eyelid . 213 

185. Fricke’s blepharoplasty . 213 

186. Blasius’s blepharoplasty . 214 

187. Blasius’s blepharoplasty . 214 

188. Hasner d’Artha’s blepharoplasty for both lids. 215 

189. Dieffenbach’s blepharoplasty . 215 

190. The Dieffenbach-Szymanowski operation . 215 

191. Knapp’s blepharoplasty . 216 

192. Outlines of incision in blepharoplasty. (Posey and Shumway.) . 216 

193. Result of blepharoplasty. (Posey and Shumway.) . 217 

194. Probes passed into the canalicuii to show their direction. (Author.) . 232 

195. Lacrimal syringe. (McFarlan.) . 233 

196. Apparatus for lavage of the naso-lacrimal duct. (Author.) . 234 

197. Lacrimal probe. (Snellen.) . 235 

198. Lacrimal probe. (Caldwell.) . 237 

199. Dermoid tumor of the conjunctiva. (Von Ammon.) . 240 

200. Microscopic section of a conjunctival dermoid tumor. (Author.) . 241 

201. Polypi of the conjunctiva. (De Beck.) . 212 

202. Subconjunctival cyst. (Author.) . 243 

203. Microscopic section of an epibulbar leucosarcoma with hematogenous pigmentation. 

(Kerschbaumer.) . 244 

204. Antero-posterior section of primary sarcoma of the conjunctiva. (Author.) . 244 

205. Growth of conjunctival epithelioma into the cornea. (De Beck.) . 245 

206. Microscopic section of an epithelioma of the conjunctiva advancing into the cornea. 

(De Beck.) . 245 

207. Eye-drop bottle (Chalk) and aseptic flask (Strosciiein) . 247 

208. Congestion of the posterior conjunctival vessels. (Author.) . 248 

209. Ciliary injection. (Author.) . 249 

210. Section of growth in the bulbar type of vernal conjunctivitis. (Danvers.). 262 

211. Trachoma follicles. (Author.) . 279 

212. Conjunctivitis petrificans. (Reif.) . 285 

213. Traumatic pterygium. (Oliver.) . 286 

214. Tuberculosis of the conjunctiva. (Eyre.) . 290 

215. Eye-speculum. (Author.) . 296 

216. Operation for pterygium. (McReynolds.) . 298 

217. Operation for symblepharon. (Teale.) . 298 

218. Operation for symblepharon. (Harlan.) . 299 

219. Excision of the upper cul-de-sac. (After Stephenson.) . 300 

220. Congenital ectasia of the cornea. (Wurdemann.) . 304 

221. Appearance of the cornea in ulcus serpens. (Knies.) . 312 

222. Creeping ulcer of the cornea. (Author.) . 313 

223. Keratitis e lagophthalmo. (Author.) . 318 

224. Section of the cornea in phlyctenular keratitis. (After Iwanoff.) . 321 

225. Section of the cornea in interstitial keratitis. (Baas.) . 322 

226. Notched teeth. (De Beck.) . 323 

227. Pegged teeth. (De Beck.) .323 

228. Trachoma with pannus. (Author.) . 326 

229. Section of the cornea in pannus. (Author.) . 327 

230. Microscopic section of growth in aspergillar keratitis. (Author.) . 330 

231. Malarial keratitis. (Kipp.) . 331 
























































































XX 


LIST OF ILLUSTRATIONS. 


FIG. PAGE 

232. Filamentary keratitis. (Hess.) .332 

233. Keratitis punctata. (Author.) . 333 

234. Appearance of the cornea in punctate keratitis. (Knies.) . 334 

235. Appearance of the cornea in ribbon-shaped opacity. (Knies.) . 335 

236. Appearance of the cornea in herpes febrilis. (Knies.) . 337 

237. Section of the cornea in striate keratitis. (Hess.) . 338 

238. Sclerosis and atrophy of the corneal limbus. (Fuchs.) . 340 

239. Staphyloma of the cornea. (Author.) . 342 

240. Keratoeonus. (Author.) . 344 

241. Keratoglobus. (After Demours.) . 345 

242. Fistulous ulcer of the cornea. (WtiRDEM ann. ) . 347 

243. True corneal fistula, showing downgrowth of epithelium. (Author.) . 348 

244. Hemorrhage into the cornea. (After de Beck.) .. 354 

245. The same eye one day later. (After de Beck.) . 354 

246. Operation for corneal staphyloma. (Knapp.) . 356 

247. Tattooing instrument. (Barck.) . 359 

248. Deep scleritis. (Author.) . 363 

249. Sclerosing keratitis. (After Demours.) . 365 

250. Equatorial ectasias of the sclera. (After von Ammon.) . 367 

251. Cirsoid ciliary staphyloma. (Vossius.) . 367 

252. Posterior staphyloma of Scarpa .368 

253. Ciliary staphyloma. (Pagenstecher and Genth.) . 368 

254. Stitch for scleral rupture. (After Nuel.) .:. 370 

255. Giant magnet .372 

256. Congenital coloboma of the iris. (Seggel.) . 374 

257. Persistent pupillary fibres, forming loops. (De Beck.) . 375 

258. Forms of persistent pupillary membrane. (De Beck.) . 375 

259. Forms of corectopia. (De Beck.) . 375 

260. Polycoria. (De Beck.) ..'. 376 

261. Cyst of the iris. (Collins.) . 377 

262. Serous cyst of the iris following discission for milky cataract. (Ayres.) . 378 

263. Cysticercus which has broken through an iridal vessel. (Kraemer.) . 380 

264. Pericorneal injection in iritis. (Author.) . 382 

265. Different appearances of the pupil in iritis, after the use of atropin . 383 

266. Gummatous iritis. (Author.) . 385 

267. Iritis with hypopyon and ehemosis. (Von Ammon.) . 386 

268. Antero-posterior section of an eye which shows post-iritic glaucoma, calcareous cata¬ 

ract, and chorioiditis. (Author.) . 3S7 

269. Proliferation of the pigment layer of the iris in diabetes. (Author.) . 389 

270. Iridodialysis. (De Beck.) . 394 

271. First step in the operation of iridectomy. (Author.) . 397 

272. Second step in the operation of iridectomy. (Author.) . 397 

273. Third step in the operation of iridectomy. (Author.) . 398 

274. Iridectomy in threatened corneal perforation . 400 

275. Instruments used in operations on the iris. (Author.) . 401 

276. Iridocapsulotomy. (De Wecker.) . 402 

277. Iridocapsulotomy. (De Wecker.) . 402 

278. Coloboma of the iris and ciliary body. (Bock.) . 404 

279. Leucosarcoma of the ciliary body and melanosarcoma of the iris. (Kerschbaumer.) . 405 

280. Gumma of the ciliary body. (Norris and Oliver.) . 406 

281. Anterior part of eyeball wdth iridocyclitis. (After Pollock.) . 408 

282. Coloboma of the chorioid. (Benson.) . 411 

283. Coloboma of the macula, -with islets of pigment and an atrophic crescent of the optic 

disc. (Silex.) . 412 

284. Metastatic carcinoma of the chorioid . 414 

285. Fungating sarcoma of the chorioid. (Author.) . 415 

286. Early stage of chorioidoretinitis. (Liebreich.) . 422 

287. Late stage of chorioidoretinitis. (Liebreich.) . 423 

288. Senile areolar atrophy of the chorioid. (Nettleship.) . 424 

289. Types of posterior staphyloma. (Galezowski.) . 425 

290. Panophthalmitis and orbital cellulitis. (W. T. Shoemaker.) . 431 

291. Section of a panophthalmitic eye. (Wurdemann.) . 432 

292. Ruptures of the chorioid. (Knapp.) . 434 

293. Colloid change in the macular region. (De Schweinitz.) . 435 

294. Binocular coloboma of the lens without coloboma of the iris or chorioid. (Author.).. 437 

295. Lenticonus anterior. (Modified from Webster.) . 438 

296. Lenticonus posterior in a buphthalmic eye. (Modified from Pergens.) . 438 

297. Congenital luxation of the lens. (De Beck.) . 439 

298. Location of opacity in different forms of cataract . 440 

299. Anterior capsular cataract of stellate form. (Von Ammon.) . 440 

300. Appearance of cataract . 441 

301. Shadow of iris seen in unripe cataract. (Fuchs.) . 442 

302. Coralliform cataract. (Author.) . 444 

303. Anterior polar cataract. (Von Ammon.) . 445 

304. Calcareous cataract. (Von Ammon.) . 446 

305. Anterior segment of a rabbit’s eye twenty-four hours after extraction of the lens. 

(Bates.) . 447 

306. Instruments for extraction of cataract without iridectomy. (Author.) . 450 

307. Incision in cataract extraction. (Author.) . 451 

308. Incision of the cornea in various methods of cataract extraction. (Nimier and 

Despagnet.) . 454 

309. Cystoid cicatrix lined by atrophied iris-tissue, in an eye in ivhich glaucoma followed 

cataract extraction. (Treacher Collins.) . 457 

310. Depression of cataract. (Agatz.) . 163 

311. Discission with two needles . 464 

312. Site of incision for traumatic cataract. (Author.) . 465 

313. Operation for post-operative cataract. (Kuhnt.) . 466 

314. Dislocation of the lens into the anterior chamber. (Von Ammon.) . 470 


















































































LIST OF ILLUSTRATIONS. . xx j 

PIG. PAGE 

315. Coloboma of the vitreous humor. (Ecker.) . 473 

316. Canal of Cloquet, with cyst in the vitreous humor. (Roller.) . 474 

317. Extensive vascular growth in the vitreous humor. (Harlan.) .-._479 

318. Rosette of neuroepithelial cells with short protoplasmic processes. (Wintersteiner. ) 483 

319. Tubulose structure of neuroepithelioma of the retina. (Wintersteiner.) . 483 

320. Neuroepithelioma of the retina. (Wintersteiner.) . 484 

321. Neuroepithelioma of the retina. (Author.) . 4S5 

322. Pseudo-neuroepithelioma of the retina. (Author.) . 487 

323. Perivasculitis of the retinal vessels. (Harlan.) . 491 

324. Arterio-venous aneurism of the retina. (Fuchs.) . 492 

325. Subhyaloid hemorrhage. (Hotz.) . 494 

326. Section of the retina in embolism of the central artery. (After Marple.) . 495 

327. Section through the optic nerve showing an embolus in the central artery. (After 

Marple.) . 496 

328. Serous retinitis. (Oliver.) . 500 

329. Macular change in infancy. (Tat.) . 512 

330. Proliferating retinitis. (Jaeger.) . .518 

331. Coloboma of the optic nerve and chorioid. (Posey.) . 529 

332. Microscopic section showing hyalin bodies in the nerve-head. (Author.) . 532 

333. Hyalin bodies in the optic disc. (Nieden.) . 533 

334. Photomicrograph of the optic-nerve head in case of tumor of the brain. (Author )... 537 

335. Fields of vision in a case of quinin-amaurosis. (Author.) . 543 

336. Deformity of the skull producing exophthalmos, divergent strabismus, and atrophy of 

the optic nerve. (Risley.) . 547 

337. Atrophy of the optic nerve following phthisis bulbi. (Author.) . 54S 

33S. Metamorphopsia varians. (Dudley.) . 560 

339. Section of normal superior cervical ganglion. (Author.) . 564 

340. Angle of the anterior chamber of a normal eye. (Author.) . 565 

341. Angle of the anterior chamber of a glaucomatous eye. (Author.) . 566 

342. Head of normal optic nerve. (Author.) . 570 

343. Head of optic nerve in glaucoma absolutum. (Author.) . 570 

344. Types of excavation of the optic nerve. (Jennings.) .•. 571 

345. Field of vision of left eye in a case of glaucoma simplex. (Author.) . 574 

346. Section of superior cervical ganglion in chronic irritative glaucoma. (Author.) . 575 

347. Section of superior cervical ganglion of the sympathetic nerve in a case of hemorrhagic 

glaucoma. (Author.) . 579 

348. Acquired hydrophthalmos. (Author.) .. 581 

349. Binocular hydrophthalmos following ophthalmia neonatorum. (Author.) . 583 

350. Appearance of pupil after iridectomy for glaucoma. 586 

351. Site of the incision for removal of the superior cervical ganglion of the sympathetic 

nerve. (Author.) . 587 

352. Operation for excision of the superior cervical ganglion of the sympathetic nerve. 

(Author.) ... 588 

353. Posterior sclerotomy. (After Czermak.) . 592 

354. Enucleation scissors ... 608 

355. Artificial-vitreous introducer. (Todd.) ... 611 

356. Sclero-optic neurectomy . 612 

357. Sphere in position. (Fox.) . 614 

358. Conformer. (Fox.) . 614 

359. Cyclops. (After Van Duyse.) . 616 

360. Anophthalmos. (Author.) . 617 

361. Fibrosarcoma of the orbit. (Wilson.) . 622 

362. Orbital tumor in a case of sarcomatosis. (W. T. Shoemaker.) ..... 623 

363. Abscess of the orbit in a child ten days old, injured during instrumental delivery. 

(Author.) . 631 

364. Thrombosis of the cavernous sinus. (W. T. Shoemaker.) . 637 

365. Avulsion of the eyeball. (Barck.) . 647 

366. Kronlein’s operation . 652 

367. Modification of Kronlein’s operation. (Parinaud and Roche.) . 653 

368. Scheme of the axes of rotation of the ocular muscles . 654 

369. Muscles associated in moving the eyeballs in the directions indicated by the arrows ... 655 

370. Illustrating the projection of the false image (colored) . 658 

371. Paralysis of the internal rectus of the right eye, producing crossed diplopia (colored).. 659 

372. Paralysis of the external rectus of the right eye, producing homonymous diplopia 

(colored) .t. 660 

373. Position of the images in ocular paralyses (colored) . 661' 

374. Mnemonic scheme of ocular paralyses. (Werner.) . 665 

375. Ophthalmoplegia. (Author.) .666 

376. Ophthalmoplegia. (Author.) ..667 

377. Measurement of the angle of squint by the perimeter . 672 

378. Linear measurement of squint . 673 

379. Relative positions of the line of light and the candle-flame in the Maddox rod test 

(colored) . 675 

380. Insufficiency of the oblique muscles . 678 

381. Tenotomy of the external rectus muscle. (Author.) . 682 

382. Advancement of an ocular muscle, showing the suture in position before tying . 683 

383. Total advancement. (Author.) . 684 

384. Capsular advancement. (Fox.) ... 685 

385. Passage of an oblique ray from a rare to a dense medium . 686 

386. Refraction by plane glass . 687 

387. Refraction by a prism . 6S7 

388. Refraction by prisms . 688 

389. Profiles of lenses . 689 

390. Emmetropic eye . 691 

391. Refraction of parallel rays of light in emmetropia, hypermetropia, and myopia. 693 

392. Inability to focus parallel rays of light on the retina of the hypermetropic eye . 694 

393. Accommodation is necessary to bring parallel rays on the retina of the hypermetropic 

eye . 694 












































































XXII 


LIST OF ILLUSTRATIONS. 


FIG. PAGE 

394. Additional accommodation power is necessary to bring an object at the near point upon 

the retina of an hypermetropic eye . 695 

395. Illustrating the focus of parallel rays of light in the myopic eye . 703 

396. Only divergent rays are brought to a focus on the retina . 704 

397. Parallel rays focused in the vitreous . 704 

398. Chart showing increase of myopia in school-children of Philadelphia. (Riseey.) -707 

399. Chart showing increase of myopia in school-children of St. Petersburg. (Erismann.). 707 

400. Chart showing disease in relation to refraction . 708 

401. Chart showing vision and pain in relation to refraction . 709 

402. Chart showing disease in relation to age . 709 

403. The cornea in emmetropia . 717 

404. Irregular astigmatism . 717 

405. Regular astigmatism . 717 

406. Regular astigmatism . 717 

407. Refraction of rays in regular astigmatism . 718 

408. Simple hypermetropic astigmatism . 719 

409. Simple myopic astigmatism . 719 

410. Compound hypermetropic astigmatism . 720 

411. Compound myopic astigmatism . 720 

412. Mixed astigmatism . 72 L 

413. “Clock-dial” chart . 722 

414. Range of accommodation at various ages. (Donders.) . 727 

415. Diagram of the visual tract (colored). 735 

416. Diagram of right homonymous hemianopsia and of the sites of lesions which may 

cause it . 737 

417. Diagram of Wernicke's pupil symptom . 738 
























LIST OF FULL-PAGE PLATES. 


PLATE FACING PAGE 

I. Coronal Section, showing the Orbits and Adjacent Parts. (Murphy.) . . 12 

II. Normal Fundus Oculi. 54 

III. Normal Fundus Oculi. 56 

IV. Normal Fundus Oculi. 58 

V. Normal Fundus Oculi: Macular and Foveal Reflexes. (Johnson.).... 60 

VI. Test-words for the Determination of Accommodation. (Oliver.). 122 

VII. External Diseases of the Eye. 180 

VIII. External Diseases of the Eye. 226 

IX. Bacteria found in Conjunctival Inflammations. (Schanz.) . 250 

X. External Diseases of the Eye. 266 

XI. External Diseases of the Eye. 308 

XII. External Diseases of the Eye. 384 

XIII. Diseases of the Cliorioid. 416 

XIV. Diseases of the Chorioid. •,.... 426 

XV- Diseases of the Retina. (Oliver.). 4S8 

XVI. Diseases of the Retina. 494 

XVII. Diseases of the Retina. 498 

XVIII. Diseases of the Retina. 504 

XIX. Diseases of the Retina. 512 

XX. Diseases of the Retina. 516 

XXI. Diseases of the Retina. 522 

XXII. Diseases of the Optic Nerve. 544 

XXIII. Diseases of the Optic Nerve: Glaucoma. 562 


(xxiii) 




































■v 











MODERN OPHTHALMOLOGY 


CHAPTER I. 

DEVELOPMENT OF THE EYE. 

The formation of the eye is initiated by a protrusion of the lateral 
walls of the primary cerebral vesicle. Thus the primary optic vesicles are 
formed, which detach themselves more and more from the brain until finally 



Fig. 1.—Transverse section through the brain of a chick : three 
days’ incubation. (Author.) 


(Original drawing by Da. Carl Fisch.) 

1, Ectoderm. 2, Cornea. 3, Mesenchyma. 4, Primitive artery. 5, Wall of brain- 
vesicle. 6, Cavity of brain-vesicle. 7, Eye-stalk. 8, Lens. 9, Cavity of eye-vesicle. 10, 
Anterior part of the retina. 11, Posterior layer of the retina. 12, Formation of lens- 
fibres. IS, Cavity of lens-vesicle. 

they are connected with it only by a slender peduncle, the eye-stalk. The 
vesicles are hollow, and their cavity communicates with the brain-cavity 
by means of the canal in the eye-stalk. The original form of the optic 

( 1 ) 


1 









o 


MODERN OPHTHALMOLOGY. 


vesicle soon undergoes a change by the appearance of two depressions on 
its lateral and inferior surfaces. The one leads to the formation of the 
lens, the other to that of the vitreous body. 

The formation of the lens begins in the human fetus at the commence¬ 
ment of the fourth week. Where the ectoderm lies over the primary optic 
vesicle, a slight thickening is observed, which soon deepens into a slight 



Fig. 2.—The secondary eye-vesicle, with lens-fossette. 

(After vox Kolliker.) 

From a human embryo of four weeks (8 millimetres long). 1, Mesoderm. 2, Ectoderm. 

3, Lens-fossette. 4, Retina. 5, Pigment layer. 

depression. The latter increases, while at the same time its borders 
approach and finally approximate and coalesce, now forming the sac of 
the lens. Simultaneously the lateral wall of the primary vesicle yields 
to this pressure, so that together with the depression it is transformed into 
a cup-like structure with double walls, through which connective tissue 
and blood-vessels grow into the cup. Thus the vitreous body, and later 

1 

2 

3 


1 

Fig. 3. —Constriction of the lens. (After Van Bambeke.) 

Human embryo of four weeks. 1, Mesoderm, g, Pigment layer. 3, Retinal layer. 

4, Vitreous. 

the arteria centralis retinae, are formed. The cup closes at a later stage 
of development. At first a defect—the fetal eye-cleft—remains, which, 
under abnormal conditions, can persist into later life. 

For some time the external and internal layers of the eye-cup are 
separated bv a space which, by way of the eye-stalk canal, connects with 
the third vesicle. Later they are found closely approximated, and conse- 




DEVELOPMENT OF THE EYE. 


3 


quently the eye-stalk is transformed into a solid mass with the arteria 
centralis retinae in its centre. Thus the optic nerve is formed. 

Aside from the formation of the vitreous, the surrounding mesoderm 
contributes, by its development, to the structure of the eye, giving origin 
to the enveloping membranes, the ehorioid and the sclera. It is now neces¬ 
sary to examine more in detail the development of the essential parts of 
the eye. 

The Lens.— The lenticular sac, after separating entirely from the 
ectoderm, is formed by two or three layers of epithelial cells. Externally 
it is surrounded by a thin membrane, the capsule, the origin of which is 
yet doubtful. Soon the anterior and posterior walls show differences in 
the shape of their cells. The anterior cells gradually transform into other 
elements, the epithelium lentis, while the posterior ones grow considerably 
in length. They form a protrusion into the cavity of the sac and change into 


Ectoderm 

Mesoderm 

Vitreous 

Cornea 

Retinal layer 
Pigment layer 

Sclera and 
ehorioid 



lens-fibres; finally the cavity is obliterated, the fibres reaching the opposite 
epithelium. The later growth of the lens is obtained by apposition, new 
fibres being evolved in a formative epithelial zone around the ecpiator of 
the lens. These new fibres are arranged in concave layers, like the scales 
of an onion. While soon after birth the metabolism of the lens is only 
slight, and is achieved by osmosis, active fetal development necessitates a 
special nutritive apparatus, the tunica vasculosa lentis, around the capsule 
of the lens. This is a membrane richly provided with blood-vessels. At 
the time of birth this membrane disappears. Rarely it persists in part, 
giving rise to the condition known as congenital atresia of the pupil. 

The Vitreous Humor. —The formation of the vitreous body begins 
with the inferior depression of the primary eye-vesicle, commencing at the 
lens and extending down on the stalk. While in the adult the vitreous does 
not possess vessels, it is provided with them during fetal life. They arise 








4 


MODERN OPHTHALMOLOGY. 


from the arteria centralis retinae, and extend to the posterior surface of 
the lens, where they spread in the tunica vasculosa and pass over to the 
anterior surface (Fig. 5). They disappear at birth, only a vestige remain¬ 
ing in the shape of the hyaloid canal. 

The account given of the development of the vitreous body is the one 
which has long been accepted. It is proper to state, however, that Eabl 
and Tornatola consider the vitreous more essentially ectodermal than meso¬ 
dermal in nature, and that it is formed from the outer layer of the primi¬ 
tive retina. Lenhossek states that the fibrillary portion of the vitreous is 
undoubtedly ectodermal in origin, being formed by outgrowths of the cells 
of the lens, and not from the cells of the inner layer of the retina. 

The Secondary Eye-cup and the Eye-membranes.—In mammals the 
cornea is a product of the mesenehyma. Soon after the separation of the 
lenticular sac from the ectoderm a thin layer of mesenehyma is found 
between them, which by migratory cells greatly increases in thickness. 



Fig. 5.—Tunica vasculosa lentis. (After O. Schultze.) 

The pupillary membrane of a human fetus of eight mouths ; the capsular membrane 
of a human embryo of six months. A piece of the uvea has been removed. 


Pupillary membrane 
Iris 

Long ciliary artery 

Short ciliary artery 
Capsular membrane 

Vitreous 


The inner layer, adjoining the capsule of the lens, represents the pupillary 
membrane (membrana vasculosa) ; the external one forms the cornea. 
These two layers become well defined only when, by a cleft between them, 
the anterior chamber begins to form. At the same time the external and 
the internal layers of the eye-cup assume different properties. The external 
remains thin and is converted into a pigmented lamella by the deposition 
due to an active proliferation of its cells. A differentiation also is seen 
between the base of the cup and its rim, the former building up the retina, 
the latter actively participating in the formation of the ciliary body and 
the . iris. The rim of the cup becomes skin and undergoes a considerable 
surface growth, squeezing itself in between the cornea and the anterior 
surface of the lens, where it leaves a small opening—the pupil. Like in 
the external layer, in this layer also pigment is deposited, which becomes 
the pigmented layer of the iris. The adjoining layer of the mesenehyma 








DEVELOPMENT OF THE EYE. 


5 


furnishes the muscular and connective-tissue stroma of the iris. As to 
the ciliary body, it suffices to say that it takes its origin equally from the 
thinned marginal zone in conjunction with the attached mesenchymal 
tissue. In the later stages of development (fourth month) firm connec¬ 
tions between this body and the capsule of the lens are produced by con¬ 
nective-tissue proliferation of the former, the zonula of Zinn. The devel- 



Fig. 6.—Scheme of the secondary eye-vesicle. 

( Manz-Ziegler. ) 

1, The lens. 2, External layer. 3, Eye-cleft. 4, Space for the vitreous body. 

5, Primary cavity of the eye-vesicle. 6, Inner layer of the secondary eye-vesicle. 

7, Wall of the hollow opticus (eye-stalk). The ventral side is turned toward the 
observer. The stalk of the optic nerve has been cut close to the eye. 

opment of the different layers of the retina must be passed by here. Early 
in ocular development the mesenchymatous layer around the eye-cup dif¬ 
ferentiates into the two membranes, the chorioid and the sclera. 

The Optic Nerve.—Owing to the two depressions formed in the pri¬ 
mary eye-cup, the eye-stalk is connected with both layers of the retina. 
The external layer continues into the pigmented epithelium, the internal 



Fig. 7.—Vertical section of the anterior half of an eye from a human 
embryo of eight or nine weeks. (After von Kolliker.) 

into the retina. The originally hollow eye-stalk gradually becomes a solid 
mass, the optic nerve, which in its distal end embraces the arteria centralis 
retinae. The way in which its primarily spindle-shaped cells transform into 
the final condition, in which especially the formation of the nerve-fibres 
is produced, is yet much discussed. Externally the mesenchyma forms two 
sheaths, one of which is continuous with the pia, while the other merges 
centrally into the dura and distally into the sclera. 













6 


MODERN OPHTHALMOLOGY. 


Development of the Retina.—The retina takes its origin from the 
internal layer of the eye-cup, while the external layer is transformed into 
the pigment-membrane. Soon after the formation of the secondary eye- 
cup, the inner layer, by an active proliferation of its cells, begins to thicken, 
and gives rise to two kinds of cells, the spongioblasts and the neuroblasts. 



Cornea 

Anterior chamber 
Stroma of the iris 

Pigment layer 


Mesoderm 
Retinal layer 


Fig. 8.—Section of two ciliary processes of a human embryo, 
enlarged 200 diameters. (After Krischewski.) 


While the former, by peculiar metamorphosis, provide the supporting 
structures of the retina (Muller’s fibres), and also form the two layers 
called the membrana limitans externa and interna, the latter are the source 
of the various nerve-cells found in the retina. A small supply of meso- 
blastic tissue furnishes the necessary amount of vascular structures (arteria 
centralis retinae). Of the nerve-cells, those near the pigment-membrane 



Fig. 9.—Eye of a human embryo of seven weeks, enlarged 
20 diameters. (Kollmann.) 

1, 2, Limit of the conjunctival sac. 3, Opening for the ear. 

undergo characteristic changes, forming processes which perforate the 
membrana limitans externa, and later on appear as the layer of rods and 
cones. While these, therefore, lie externally to the said membrane, the 
nucleated cell-bodies remain on its inside, and appear as the external 
nuclear layer. Their axis-cylinder processes take their course toward the 
centre of the eyeball. The remaining part of the retinal nerve-cells gives 










DEVELOPMENT OF THE EYE. 


JV 

4 


rise to the other layers, some becoming the bipolar cells of the inner nuclear 
layer and others forming the large ganglion-cells of the ganglion-cell layer. 
All of them converge toward the papilla, where they pass through the retina 
and the two connective-tissue sheaths of the eye-cup to appear as optic- 
nerve fibres. The sensory epithelium is formed latest in the course of 
development. In some mammals (cats and dogs) it appears only after 
birth. 

The part of the retinal layer from the ora serrata to the pupillary 
opening is not differentiated like the retina in the fundus of the eye. Its 
two divisions, the lenticular and the marginal zone, enter into the formation 
of the ciliary body and iris. 

The manner of formation of the optic-nerve fibres is still in dispute. 
Some observers claim that they arise from the ganglion-cells of the thalami 
optici and the anterior corpora quadrigemina, while others maintain that 
they are nothing but the prolonged axis-cylinders of the retinal ganglion- 
cells. 

A well-developed area centralis is seen in the fifth or sixth month, 
while the formation of the fovea does not occur until the eighth month. 
The distribution of the capillary system from the arteria centralis is 
complete by the sixth month. 

Accessory Organs of the Eye.—The upper and lower eyelids are formed 
by two folds of the external skin, which grow from above and below over 
the cornea until they meet. In many mammals, and so, too, in man, they 
coalesce with their epithelial margins (third month). Shortty before birth 
they again separate. By these two folds the conjunctival sac is formed. 
At the time of coalescence, by proliferation of the rete Malpighii, the glands 
of Meibomius are seen to grow into the lids as solid, finger-like projections, 
on which small lateral buds develop later. The solid glands acquire lumina 
by the central cells undergoing fatty degeneration and solution. Simul¬ 
taneously cilia arise, the development of which does not differ from that 
of other hair-follicles. The lacrimal gland appears during the third month. 
It is formed by epithelial proliferation of the conjunctival sac at the outer 
part of the eye, where the upper lid merges into the eyeball. As to the 
lacrimal canal, it must suffice to say that it originates very early from a 
solid strand of cells in which a lumen forms. The same is true of the 
canaliculi. 


CHAPTER II. 

ANATOMY OF THE EYE. 


THE ORBIT. 

The eye is placed in the bony cavity known as the orbit. (The orbits 
are two in number and are situated at the upper and anterior part of the 
face.) Each orbit is pyramidal in shape, and presents a base, an apex, 
four sides, and four angles, and is composed of seven bones, viz.: frontal, 


Sinus front. 



Lamina papyr. 098 . ethmoid. 


For. 


For sphenopalat. 


Spina trochlear. 

Kara orbit, oss. front. 


Os lacrimale 


Fossa sacci lacrim. 
Os nasale 


Sonde im 
canal, pteryg 


Fossa pterygopalat. 


Foramina ethmoid. 
Proc. orbit, oss. palat. 
Corpus oss. sphenoid. 

For. optic. 

Fissura orbit, sup. 

Sella turcica 


orbit, maxill. 


Proc. uncin. oss. 
ethmoid. 

Proc. ethmoid, conchae 
nasal, inf. 

Proc. maxill. conchae 
nasal, inf. 


Sinus maxillaris 
Pars perpendic. oss. palat. 


Lamina lat proc. pteryg. 

Proc. pyramid, oss. palat. 


Sonde in canal, palat. 


Fig. 10.—Inner wall of the orbit and adjacent parts. (His.) 


sphenoid, ethmoid, superior maxillary, malar, palate, and lacrimal. Three 
of these—the frontal, sphenoid, and ethmoid—enter into the formation of 
both orbits. Hence, while each orbit is composed of seven bones, the two 
are made up of eleven bones only. The apex is directed upward and in¬ 
ward, the base downward and forward. If continued, the axes of the 
orbits would cross in the region of the sella Turcica of the sphenoid. 
The roof of the orbit is formed by the orbital plate of the frontal bone 
in front, and the lesser wing of the sphenoid behind. It is concave, and 
at its external and anterior part presents a depression, the lacrimal fossa, 
which marks the site of the lacrimal gland. The roof is always thin and 

(3) 







ANATOMY OF THE EYE. 


9 


sometimes is wanting in part. In such instances the dura mater and 
periorbita are in contact. Internally and anteriorly the roof presents a 
depression, the trochlear fossa, for the pulley of the superior oblique 
muscle. The floor slopes downward, forward, and outward, and is made 
up of the orbital plate of the superior maxilla, the orbital process of 
the malar, and the orbital plate of the palate hone. The inner wall 
is formed from the nasal process of the superior maxilla, the lacrimal, 
ethmoid, and sphenoid hones. The outer wall is formed from the orbital 
process of the malar and the great wing of the sphenoid. Each orbit 
is in relation with the cranial cavity above, the antrum of Highmore 
below, the temporal fossa externally, and the nasal cavity, frontal, 
ethmoidal, and sphenoidal sinuses internally. The depth of the orbit 
is one and three-fourth inches and is much increased by the addition 
of the soft parts. Foreign bodies of large size have lodged in the 
orbit, where their presence w T as unsuspected. The orbit is lined by 
periosteum derived from the dura mater. This is attached closely to the 
optic foramen and sphenoidal fissure behind, and to the margin of the 
orbit in front, where it is continuous with the periosteum covering the 
bones of the face. The walls of the orbit in front form a strong bony ring, 
the orbital margin. This protects the eye against external force, par¬ 
ticularly above and below, where the margin projects farthest. Internally 
there is no well-defined orbital margin, but here the nose protects the eye. 
Externally the margin recedes, and here the eye is most exposed to injury. 

Foramina.—Nine foramina communicate with each orbit. They are 
the optic foramen, sphenoidal fissure, malar canals, anterior and posterior 
ethmoidal, supra- and infra-orbital foramina, spheno-maxillary fissure, 
and the canal for the nasal duct. The optic foramen, placed above the level 
of the middle of the eye, is a round opening at the apex of the orbit, 
situated between the two roots of the lesser wing of the sphenoid bone. 
It transmits the optic nerve and the ophthalmic artery. The sphenoidal 
fissure, or foramen lacerum anterius, also situated at the apex, is a slit¬ 
like opening between the greater and lesser wings of the sphenoid. It 
transmits the third, fourth, and sixth nerves; the frontal, nasal, and 
lacrimal branches of the ophthalmic, or first division of the fifth, nerve; 
filaments from the cavernous plexus of the sympathetic nerve, the orbital 
branch of the middle meningeal artery, the recurrent lacrimal artery, and 
the ophthalmic vein. 

The malar, or zygomatico-temporal canals, are small openings which 
run from the orbital plate of the malar bone to the external surface of 
the same, and serve for the passage of nerves and vessels. The ethmoidal 
foramina are two grooves in the upper surface of the os planum. They are 
converted into foramina by the articulation of the frontal bone with the 
ethmoid. The anterior ethmoidal foramen transmits the nasal nerve and 
anterior ethmoidal artery; the posterior ethmoidal foramen gives passage 
to the posterior ethmoidal artery. The supra-orhital foramen, often only 


10 


MODERX OPHTIIALMOLOGV. 


a notch, is situated in the supra-orbital margin of the frontal bone at the 
junction of the inner with the middle third. It can be felt in the living 
subject, and transmits the supra-orbital vessels and nerve. The infra¬ 
orbital foramen, which opens upon the facial surface of the superior max¬ 
illa, begins as a groove in the orbital surface of the superior maxillary bone. 
It passes forward and terminates in a canal which has two branches. One 
of these ends in the infra-orbital foramen; the other runs in the anterior 
wall of the antrum and is called the anterior dental canal. It transmits 
the anterior dental vessels and nerve to the front teeth of the upper jaw. 
The infra-orbital foramen is for the passage of the infra-orbital vessels 
and nerve. The spheno-maxillary fissure forms the external boundary of 



Fig. 11.—Frontal section showing the relation of the orbits to the 
other cavities of the skull. (After Zvckerkandl.) 

A, Roof of interorbital space, a, a, a, The three nasal meati. 6, Middle turbinated bone, 
c, Olfactory fissure, d, Respiratory region. B, Floor of the nasal chambers. 

the floor of the orbit. It is formed chiefly by the orbital plate of the supe¬ 
rior maxillary bone, with a small part of the malar in front and the orbital 
plate of the palate bone behind. It transmits the superior maxillary nerve 
and its orbital branch, the infra-orbital vessels, and ascending branches 
from Meckel’s ganglion. By means of the spheno-maxillary fissure the 
orbit communicates with three fosstu: the temporal, zygomatic, and spheno¬ 
maxillary. The canal for the nasal duct is at the inner and anterior part 
of the orbital floor. It begins with the lacrimal groove, a depression formed 
by the lacrimal bone and the nasal process of the superior maxilla. The 
canal runs downward, outward, and backward, and opens into the inferior 
meatus of the nose, beneath the anterior part of the inferior turbinated bone. 









ANATOMY OF THE EYE. 


11 


Interorbital Space. —This includes the nasal and lacrimal hones, the 
ascending processes of the superior maxillary bones, the frontal below the 
level of the supra-orbital foramina, and the lateral masses and perpendic¬ 
ular plate of the ethmoid bone. 

Orbital Contents. —The orbit contains periosteum, adipose and con¬ 
nective tissue, the eyeball, muscles, vessels, nerves, glands, and ganglia. 
These form a soft cone, which fits accurately into the orbit. 

The Periosteum is derived from the dura mater. The dura is closely 
attached to the sphenoidal fissure and optic foramen, in front of which 
it divides into two layers. The outer one forms the periorbita and the 
inner divides the orbital contents into different compartments. This layer 
will be described under the name of the capsule of Tenon. The peri¬ 
orbita runs forward to the base of the orbit. It is closely attached to the 
orbital margin, and disappears in the periosteum covering the bones of 
the face. It is loosely connected with the walls of the orbit. Hence, in 


fracture with effusion of blood or in cases of purulent collection, this 
membrane may be extensively removed from the bone. 

The Capsule of Tenon, or oeulo-orbital fascia, insheathes all the 
organs which pass through it, forms an acetabulum in which the eyeball 
rests, is continuous with the sheath of the optic nerve, forms a secondary 
attachment for the ocular muscles, and prevents morbid collections in the 
orbit from reaching the surface. It covers the posterior four-fifths of the 
eyeball (except a space one centimetre in diameter in the middle of which 
the optic nerve passes) and here consists of two layers, between which is 
Tenon’s space. This is continuous with the subdural and subarachnoidal 
spaces of the optic nerve. The capsule of Tenon divides and subdivides, 
forming a covering for every tissue in the orbit. Some anatomists limit 
Tenon’s capsule to that part of the fibrous envelope of the eyeball in 
front of the point where it is pierced by the ocular muscles, and they give 
the name of Bonnet’s capsule to the part behind. Tenon’s space, accord¬ 
ing to Schwalbe, is a lymph-space; but this is denied by Langer. That 
part of the dura which surrounds the optic nerve from its entrance through 



Fig. 12.—Capsule of Tenon. (Merkel.) 




12 


MODERN OPHTHALMOLOGY. 


the optic foramen to the posterior surface of the eyeball is known as 
Bonnet’s sheath, or the dural covering of the nerve. 

The Orbital Muscles are seven: four recti, two obliqui, and the 
levator of the upper lid. All of them, except the levator, are attached to 
the eyeball. The levator is attached to the tarsal plate of the upper eyelid. 
All except two of the muscles are supplied by the motor oculi nerve. The 
exceptions are the superior oblique and the external rectus. The former 
is controlled by the patheticus, the latter by the abducens nerve. All of 
the orbital muscles except the inferior oblique arise from the bone around 
the optic foramen and run forward to be attached to the eyeball at different 
distances from the cornea. The muscles pierce the capsule of Tenon in 
front of the equator, and they receive sheaths from the capsule. The sheath 
becomes inseparable from the tendon on the ocular surface or side of 



Fig. 13.—Horizontal section of the right orbit, viewed from above. 

(After Gerlach.) 

1, Horner’s muscle. 2, Septum orbitale. S, Fibres of the orbicularis palpebrarum muscle. 

4, Tarsal plate. 5, Conjunctival sac. 6, Outer palpebral ligament. 7, Temporal muscle. 8, Wall 
of the orbit. 9, External rectus muscle. 10, Orbital fat. 11, Optic nerve. 12, Internal rectus 
muscle. IS, Inner check ligament. 14, Inner wall of the orbit. 15, Attachment of the capsule 
of Tenon to the conjunctiva. 16, Capsule of Tenon. 17, Tenon’s space. IS, Outer check 
ligament. 19, Lacrimal gland. 20, Ciliary process. 21, Iris. 

piessure, but on the orbital surface it is commonly separable. According 
to numerous measurements made by Fuchs, the insertion of the internal 
rectus is 5.5 millimetres from the cornea; of the external rectus, 6.9 milli- 
meties, of the superior rectus, 7.7 millimetres; of the inferior rectus, 
6.-> millimetres, of the superior oblique, 16 millimetres; and of the inferior 
oblique, 17.3 millimetres. XJnstriped muscular fibres radiating from the 
deep margin of the tarsus to the orbit have been named Muller’s muscle. 
they aie moie numerous in the upper than in the lower eyelid. Fibres 
of the capsule of Tenon pass from the anterior extremity of each muscle 
and find attachment in the sclera. It is for this reason that after the 




FLUTE I, 


Coronal Section Showing the Droits and Adjacent FartSi 

(Courtesy of Dk. Joh.v W. Mcbpht, of Cincinnati.) 



The section has been made two inches posterior to the supra-orbital. 
ridges, 1, Scalp, 2, 2, Tables of the frontal bone, 3, Superior lcngitudina It 
sinus, 4, 4, Cerebrum cut through the frontal gyri, 5, Falx cerebri.' 
B, E, Olfactory bulbs, 2, 2, Ethmoidal cells, B, B, Superior turbinated 
bodies, 9, Hiatus semilunaris and ostium maxillara, 10, 10, Antra of 
Highmore, 12, 12, Middle turbinated bodies, 13, 13, Inferior tuTbinated 
bodies, 14, Nasal septum, IS, Inferior nasal meatus, IB, Middle meatus. 
12, Superior meatus, IB, IB, Nostrils. 19, Superior maxillary banal 
20, Oral cavity. 21, Tongue, 22, 22, Inferior maxillary bone, 23, 23, Optic 
nerves. 24, 24, External recti muscles. 25, 25, Internal recti mus ’les.X 
2B, 2B, Inferior recti muscles, 22, 22, Superior recti muscles, 




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ANATOMY OF THE EYE. 


13 


operation of tenotomy the affected muscle is able to exert an active, although 
reduced, influence. After tenotomy the reattachment of the muscle is more 
by the capsule of Tenon and the conjunctiva than by the tendon. The 
levator palpebral superioris arises from the common origin above the rectus 
superior, passes forward, becomes fleshy, widens out to form an elongated 
triangle, and is inserted on the anterior surface of the upper tarsal plate. 
A few fibres are inserted into the sheath of the palpebral muscle and skin 
of the upper lid. The levator is in relation above with the frontal nerve, 
supra-orbital artery, and periorbita; below with the rectus superior and 
upper lid. It is sometimes absent, producing congenital ptosis. The 



Fig. 14.—Position of eyeball in the right orbit and the location 
of the orbital muscles. (Merkel.) 

Lp, Levator palpebrse superioris. Os, Superior oblique. Rs, Superior rectus. RI, External 
rectus. Oi, Inferior oblique. Ri, Inferior rectus. Rm, Internal rectus. Tr, Trochlea. 

rectus superior, the weakest of the recti muscles, arises from the upper 
margin of the optic foramen, and passes forward beneath the levator. It 
is in relation with the levator above, and sends a small muscular bundle 
to it. Below, it lies upon the orbital fat, which surrounds the optic nerve, 
and is also in relation with the nasal nerve, ophthalmic artery and vein, the 
capsule of Tenon, and the globe of the eye. The superior oblique extends 
from the common origin to the internal angular process, where it becomes 
tendinous, passes through a pulley, and bends suddenly backward, outward, 
and downward at an angle of 30 degrees. The tendon passes beneath the 
superior rectus muscle, and is inserted into the posterior part of the sclera. 






1-1 


MODERN OPHTHALMOLOGY. 


on a level with the equator of the eye, and midway between the superior 
and external recti muscles. The superior oblique is in relation above with 
the periorbita and fourth nerve; the tendon is in relation with the superior 
rectus. Below, the muscle is in relation with the nasal nerve and upper 
border of the internal rectus. The trocldea is a curved tubular pulley 
of hyalin cartilage fastened by fibrous tissue to the trochlear fossa of the 
frontal bone. A true synovial membrane is rarely found lining the trochlea. 
The reflected tendon, nearly twenty twenty-fifths of an inch long, is cov¬ 
ered with a loose sheath derived from Tenon’s capsule. The external rectus 
arises by two heads, between which pass the motor oculi nerve, the nasal 


5 4 



Fig. 15.—The right orbit opened from behind. (Author.) 

(Original drawing bv Du. R. W. Mills.) 

1, Optic nerve. 2, External rectus. 3, Lacrimal gland. 4, Levator palpebrae 
superioris. 5, Superior rectus. 6, Superior oblique. 7, Trochlea. S, Internal rectus. 

9, Inferior oblique muscle. 

branch of the ophthalmic division of the fifth nerve, the sixth nerve, and 
the ophthalmic vein. The muscle passes forward, diverging at an angle 
of GO degrees from its fellow in the opposite orbit, and is inserted into the 
sclera. It is in relation externally with the periorbita; internally, with 
the fatty cone, capsule of Tenon, ciliary ganglion, ophthalmic artery, and 
nasal nerve. The rectus intern us, the strongest of the series, passes from 
the optic foramen forward, being nearly parallel with its fellow, and is 
inserted into the sclera by a tendon which is concave forward. Its upper 
edge is in relation with the nasal nerve and ethmoidal vessels. The rectus 





1 


ANATOMY OF THE EYE. 15 

inferior, tlie shortest of the series, passes from the margin of the optic 
foramen to the sclera, and is attached at a point midway between the 
internal and external recti. The capsule of Tenon covering its tendon gives 
off slips to the lower lid in front of the tarsal plate and to the lower fornix. 
This muscle is in relation with the optic nerve, fatty cone, ciliary ganglion, 
and ciliary nerves above, while below adipose tissue separates it from the 
floor of the orbit. The inferior oblique, the only orbital muscle which does 
not arise from around the optic foramen, takes its origin from the orbital 



Fig. 16.—Sagittal section of the orbit. (After Deaver.) 


1, Levator palpebr* superioris. 2, Superior rectus. 3, Orbital fat. 4, Capsule of Tenon. 

5, Orbital fascia. 6, Connection between the superior rectus and levator palpebrse superioris. 

7, Capsule of Tenon. 8, Fornix of the conjunctiva. 9, Septum orbitale, or orbito-tarsal liga¬ 
ment. 10, Supravaginal lymph-space. 11, Dural sheath of optic nerve. 12, Intervaginal 
lympli-space. 13, Periosteum of orbit. 74, Capsule of Tenon. 15, Orbital fascia. 16, Inferior 
oblique muscle. 17, Check ligament of inferior rectus muscle. IS, Capsule of Tenon. 19, Or¬ 
bito-tarsal ligament. • 

plate of the superior maxillary bone at a point just external to the lacrimal 
groove. Its small, fleshy belly passes backward, outward, and a little up¬ 
ward, to be inserted into the sclera between the external and superior recti, 
and slightly nearer the optic nerve than the insertion of the superior 
oblique. As it lies in the orbit it is a flat band whose surfaces look upward 
and downward, respectively. 

Check Ligaments. —Xear the insertions of the recti muscles the 
anterior layer of the orbital fascia forms strong, band-like processes called 



















16 


MODERN OPHTHALMOLOGY. 


check ligaments. They extend laterally from the external rectus and 
internal rectus to the malar and lacrimal hones, respectively (IS, 13, in 
Fig. 13). Superiorly a similar band connects the superior rectus muscle 



Fig. 17.—Dissection of base of left orbit. (Author.) 

(Original drawing by Du. R. W. Mills.) 

This shows the insertion of the levator palpebrse superioris, the lacrimal gland, 
pulley of the superior oblique muscle, and orbital fat. 

with the levator palpebras (6, in Fig. 16). Interiorly a fibrous band passes 
from the rectus inferior to a process from the obliquus inferior muscle, 
the conjoined band being attached to the floor of the orbit. The check 



Fig. 18.—Distribution of the third and sixth nerves in 
the orbit. (Leveille.) 

1, The third nerve. 2, Its superior division. 3, Its inferior division. 4, Branch 
to the inferior oblique muscle. 5, The sixth nerve, distributed to the external 
rectus muscle. 

ligaments prevent extreme muscular action, and after tenotomy prevent 
deep retraction of the muscles. By acting on the posterior hemisphere 
of Tenon's capsule they oppose excessive backward traction on the part 


















ANATOMY OF THE EYE. 


17 


of the recti muscles. In addition to the cheek ligaments, other connective- 
tissue fibres pass in an irregular manner from one muscle to another (Howe). 

Nerves of the Orbit. —The nerves contained in the orbit are the 
optic, motor oculi, patheticus, three branches of the ophthalmic division 
of the fifth, the abducens, and filaments from the cavernous plexus of the 
sympathetic. The optic nerve will be described later. 

The Motor Oculi, or third nerve, enters the orbit via the sphenoidal 
fissure, where it has already divided into two branches: a superior and 
an inferior. The former supplies the levator palpebrae and rectus supe¬ 
rior, while the latter is distributed to the internal and inferior recti mus¬ 
cles and to the inferior oblique. The inferior branch also is distributed to 
the ciliary muscle and iris through the ciliary ganglion. The motor oculi 



Fig. 19.—Ophthalmic division of the fifth nerve. (L£veiix£.) 

1 , Skin of the forehead, turned down. 2 , Optic nerve. 3 , Third nerve. 
4, Fourth nerve. 5 , Ophthalmic division of the fifth nerve. 6, Lacrimal branch. 7, Union 
of the fourth nerve with the lacrimal branch of the fifth. S, Frontal. 9 , Nasal. 
10 , Internal branch of nasal. 


supplies all the muscles of the orbit except two: the superior oblique and 
the external rectus. The motor oculi contains about 15,000 fibres, which 
are distributed to five muscles containing about 40,000 muscular fibres. 

The Ciliary, or Lenticular, Ganglion, sometimes called the ophthalmic 
ganglion, is a small quadrate body about the size of a pin’s head. It is 
placed at the back part of the orbit internal to the external rectus muscle. 
It can be found by tracing the branch of the third nerve to the inferior 
oblique backward, when the ganglion will be seen. The ganglion receives 
the long root of the nasal nerve at its upper posterior angle; into its 
lower posterior angle the short, thick root passes from the nerve to the 
inferior oblique; and several fine filaments from the cavernous plexus of 
the sympathetic enter its posterior border. The branches from the ciliary 





IS 


MODERN OPHTHALMOLOGY. 


short ciliary nerves. These pass forward in the perineural space, accom¬ 
panying the short ciliary arteries, and each branch divides into several, 
so that there are about twenty nerves. They pierce the sclera, pass forward 
in delicate grooves on its inner surface, and are distributed to the ciliary 
muscle, iris, and cornea. Before reaching the eyeball they are joined by 
filaments from the nasal nerve. The branches of communication of the 
ciliary ganglion are: the motor branch from the motor oculi; the sensory, 
from the nasal nerve; and the sympathetic, from the cavernous plexus. 

The Fourth , or Patheticus, Nerve, the smallest of the cranial nerves, 
enters the orbit via the sphenoidal fissure, and is distributed to the superior 
oblique muscle on its upper surface. It consists of about 2000 coarse 
fibres, which innervate a muscle having about the same number of fibres. 



Fig. 20.—Lateral view of the orbit, showing the nerves. 
(After Deaver.) 


1, Antrum. 2, Bristle in the antrum. 3, Loop between orbital and lacrimal nerves. 

4, Tarsal plate. 5, Lacrimal gland. 6, Tendon of superior oblique. 7, Pulley of the same. 

8, Infundibulum. 9, Frontal sinus. 10, Supra-orbital nerve. 11, Supratrochlear nerve. 

12, Levator palpebrse muscle. 0, Lacrimal nerve. J, Superior rectus muscle A, Frontal 
nerve. 13, Internal rectus muscle. 14, Optic nerve. 15, Short ciliary nerve. 16, Nisal nerve. 

17, Ciliary ganglion. 18, Lacrimal nerve. 19, Motor oculi nerve. 20, Patheticus nerve. 

21, Abducens nerve. 22, Ophthalmic division of fifth nerve. 23, Gasserian ganglion. 24, Fifth 
nerve. 25, Inferior maxillary nerve. 26', Superior maxillary nerve. 27, Orbital nerve. 

The Ophthalmic Nerve , one of the three primary branches of the 
great fifth nerve, enters the orbit via the sphenoidal fissure, after dividing 
into the frontal, lacrimal, and nasal nerves. The frontal nerve passes 
between the periorbita and the levator muscle. Immediately behind the 
margin of the orbit it divides into supratrochlear and supra-orbital branches. 
The former escapes from the orbit internal to the trochlea and supplies the 
periosteum, the skin at the root of the nose, and inner part of the upper 
eyelid. The latter emerges via the supra-orbital foramen and supplies the 
upper eyelid, periosteum of the forehead, and scalp. The lacrimal nerve 
sends branches to the lacrimal gland, conjunctiva of the external canthus. 















ANATOMY OF THE EYE. 


19 


and upper eyelid, and gives off an inferior branch, which joins branches 
of the superior maxillary nerve. Branches from the resulting arc supply 
the lacrimal gland. Stimulation of either stem of this loop causes lacrima- 
tion. Division results in the pouring out of a paralytic secretion. The 
nasal nerve enters the orbit between the heads of the external rectus, passes 
obliquely across the orbit, enters the anterior ethmoidal foramen, passes 
between two fronto-ethmoidal cells, enters the cranial cavity, crosses the 
ethmoidal plate, enters a slit by the side of the crista galli, grooves the 
inner surface of the nasal bone, and divides into three branches. These 
are distributed to the nasal mucous lining and the skin as far as the tip 
of the nose. Before entering the ethmoidal foramen the nerve gives off 
branches to the ciliary ganglion, and the long ciliary nerves which pierce 
the sclera and end in the eyeball. These will be described with tire eye. 

The Sixth, or Abducens, Nerve enters the orbit via the sphenoidal 
fissure between the heads of the external rectus, and supplies that mus¬ 
cle. It neither gives off nor receives branches in the orbit. 

Mechel's Ganglion, or the spheno-palatine ganglion, deeply placed in 
the pterygo-maxillary fossa, gives off orbital branches. These reach the 
orbit via the spheno-maxillary fissure, and are distributed to the periorbita. 
It is by means of these that a communication exists between the spheno¬ 
palatine and the ciliary ganglia. 

The Cervical Sympathetic. —This part of the nervous system is of 
importance to the ophthalmologist, since all sympathetic fibres passing 
to the orbit traverse the superior cervical ganglion, except possibly those 
which follow the course of the fifth nerve. The cervical portion of the 
nerve consists of three ganglia and the intervening strands. 

The superior cervical ganglion, the largest of the three, is a fusiform 
body about an inch in length, and is placed in front of, and internal 
to, the transverse processes of the second and third vertebrae. It gives 
branches to the anterior divisions of the first four cervical nerves, to the 
hypoglossal, one to each of the ganglia of the vagus, one to the petrous 
ganglion of the glosso-pharyngeal, several to the carotid arteries, the 
pharynx, several cardiac branches, and branches to the small deep petrosal 
nerve, the cavernous plexus, the third and fourth nerves, and the oph¬ 
thalmic division of the fifth. The sympathetic root of the lenticular 
ganglion passes into the orbit either separately or in conjunction with 
the nasal branch of the fifth nerve. 

The middle sympathetic ganglion, placed opposite the sixth cervical 
vertebra, is smaller than the superior, and is sometimes absent. It gives 
communicating branches to the fifth and sixth cervical nerves, vascular 
branches to the inferior thyroid artery and thyroid gland, and a middle 
cardiac branch. 

The inferior cervical ganglion lies on the neck of the first rib. It 
sives branches to the seventh and eighth cervical nerves, to the vertebral 
artery, and to the deep cardiac plexus. 


20 


MODERN OPHTHALMOLOGY. 


Blood-vessels of tiie Orbit. —The Arteries of the orbit are derived 
from the internal carotid by way of the ophthalmic. The ophthalmic artery 
is given off from the cavernous portion of the carotid almost at a right 
angle: a fact which explains the infrequency of embolism of the oph¬ 
thalmic or of its branches as compared with the same process in the vessels 
of the brain. It enters the orbit through the optic foramen, lying below 
the optic nerve, and gives off ten branches, as follows: (1) lacrimal, (2) 
posterior ciliary, (3) supra-orbital, (4) central retinal, (5) posterior eth¬ 
moidal, (6) anterior ethmoidal, (7) palpebral, (8) muscular, (9) frontal, 
and (10) nasal. The lacrimal artery is the largest branch. It passes above 
the rectus externus muscle to the lacrimal gland, to which it gives branches. 
Then it leaves the orbit at the superior external angle and terminates in 
the external palpebral. The lacrimal sends a recurrent branch through 



Nasal 

Anterior ethmoidal 
Muscular trunk 

Ciliary 

Arteria centralis 
Posterior ethmoidal 


Optic nerve 
Internal carotid 


Fig. 21.—The ophthalmic artery and its branches, viewed from 
above. (After Merkel and Kallius.) 


the sphenoidal fissure to anastomose with the middle meningeal artery. 
Other branches pass to the malar foramina, the periorbita, the external 
and superior recti, and levator palpebrte muscles. The posterior ciliary 
arteries are of two sets, the short and the long. The short ciliary arteries, 
from four to ten in number, arise from the lacrimal as it crosses the optic 
nerve. They run forward in a tortuous course surrounding the nerve, and 
pierce the sclerotic perpendicularly near the optic nerve. Before reaching 
the sclera each artery divides, so that the short ciliary arteries are from 
fifteen to twenty in number. The further course of these vessels will be 
traced in connection with the anatomy of the eyeball. The long ciliary 
arteries are two in number; they also run forward and pierce the sclera. 
The supra-orbital artery, usually a small branch, arises on the inner side 
of the superior rectus muscle over the optic nerve, passes out of the orbit 
via the supra-orbital notch or foramen, and ends on the forehead, where 























ANATOMY OF THE EYE. 


21 


it supplies the occipito-frontalis muscle and the periosteum. In its course 
it gives off diploic branches to the frontal sinus and diploe. The central 
retinal artery is a minute vessel which enters the optic nerve from beneath, 
passes forward in the substance of the nerve, and enters the eyeball, where 
it supplies the retina. The comes nervi ischiadici and the central retinal 
are the only arteries in the human, subject which traverse the substance 
of nerves for any considerable distance. The posterior and anterior eth¬ 
moidal are small vessels which pass to the ethmoidal cells and dura mater. 
The muscular branches are twigs which supply the ocular muscles. The 




Fig. 22. — Distribution of the ophthalmic vein. ( Gtjrwitsch. ) 


frontal artery escapes at the upper internal angle of the orbit and supplies 
the inner part of the upper lid and the brow. The nasal artery pierces 
the orbicularis palpebrarum muscle over the internal palpebral ligament, 
passes along the root of the nose to anastomose with terminal branches of 
the facial artery, and sends branches to the lacrimal sac, canal, and 
caruncle, and to the vessel of the opposite side. 

The Veins of the Orbit are commonly described as two in number: 
the superior ophthalmic and the inferior orbital veins. The superior 
ophthalmic vein, which forms the largest channel by which blood from 
the face and head can enter the cavernous sinus, starts from the inner and 



22 


MODERN OPHTHALMOLOGY. 


upper part of the orbit, where it communicates with the frontal and facial 
veins, and passes backward to the sphenoidal fissure. On the way it receives 
branches from the eyeball, the ocular muscles, the ethmoidal cells, and from 
the inferior orbital vein. This vein is an important factor in many ocular 
diseases. One of the principal causes of thrombosis of the cavernous sinus 
is infective inflammation within the orbit, passing backward through the 
veins. The inferior ophthalmic vein lies at the floor of the orbit between 
the inferior and external recti muscles, and begins in venules derived from 
the facial and malar veins. Through the spheno-maxillary fissure it com¬ 
municates with the pterygoid plexus, into which it often empties, although 
it may end in the superior ophthalmic vein, with which it always anas¬ 
tomoses. 

The Intermuscular Cone of Fat. —The interstices between the 
orbital contents are filled with adipose tissue, and the whole is bound 
together by fasciae. Adipose tissue is placed within the muscular cone. 
Its anterior surface is concave to fit the eyeball and is lined with Tenon's 
capsule. Adipose tissue is also present outside of the cone, between the 
muscles and the periorbita. 

Lymph-vessels and Lymphatics. —These are wanting in the orbit. 

Position of the Eyeball.-—The globe is placed not in the axis of the 
orbit, but below and external to it. The prominence of the eyeball is 
largely dependent upon the amount of adipose tissue in the orbit; the 
greater the amount of adipose, the greater is the prominence. In emaciated 
subjects the eyeballs are sunken from diminution of the fat of the orbit. 

The Lacrimal Apparatus.—This consists of the lacrimal gland of the 
orbit, the accessory lacrimal glands found in the lids, the puncta, cana- 
liculi, sac, and the nasal duct. The lacrimal gland, a compound racemose 
gland about the size of an almond (larger in the negro than in the Cau¬ 
casian), is attached by connective tissue to the periosteum at the upper 
and outer part of the base of the orbit, in a depression known as the lac¬ 
rimal fossa. Its secretion obtains exit by a number of ducts (six to ten) 
which open upon the conjunctiva near the outer canthus, above the outer 
tarsal plate. 

The accessory lacrimal glands are about forty in number. The largest 
of these is the one ordinarily described by anatomists. It occupies the 
loose connective tissue of the eyelid at its temporal extremity, being 
separated from the orbital lacrimal gland by its capsule, the levator mus¬ 
cle, and Muller’s muscle. In many subjects the lobules of this gland 
invade the lower lid, as well as the upper. It presents several ducts, and 
is composed of a varying number of lobules. Other accessory glands are 
found in the connective tissue of the fornix of the conjunctiva, partic¬ 
ularly in the temporal half of the lid, although a few are situated near 
the inner canthus. All these glands present the same lobulated structure. 
Their ducts are lined with cylindric epithelium. The orifices of the ducts 
are surrounded by lymphoid infiltration: a condition causing the erroneous 


ANATOMY OF TIIE EYE. 


23 


belief that in the normal conjunctiva of man lymph-follicles exist. Wal- 
deyer and Alt have never found true lymph-follicles in the human con¬ 
junctiva. the orbital lacrimal gland, the largest of the accessory glands, 
and probably the smaller ones also, receives branches,from the facial and 
probably from the sympathetic. According to Goldzieher, the secretory 
nerve of the lacrimal gland is not the fifth, hut the facial nerve, whose 
fibres run through the large superficial petrosal nerve to the spheno-palatine 
ganglion and thence to the second branch of the fifth nerve. 



Fig. 23.— The nasal duct and lacrimal gland. (Author.) 

(Original drawing by Da. K. W. Mills.) 

The lacrimal gland has been pulled forward from its bed. 


The excretory part of the lacrimal apparatus begins with the panda 
lacrimalia, which are minute orifices situated at the inner end of each 
lid-margin. They mark the beginning of the canaliculi. Each canaliculus 
consists of a vertical part, from 1.5 to 2 millimetres in length, and a hori¬ 
zontal part which measures 7 or 8 millimetres. They end in the lacrimal 
sac, either by separate orifices or by a conjoint opening. The canaliculi 
are lined with eight to twelve layers of laminated polygonal pavement 
epithelium. The lacrimal sac, situated in a bony depression at the inner 




24 


MODERN OPHTHALMOLOGY. 


lower angle of the orbit, is placed behind the tendo oculi and in front of 
Horner’s muscle. Its upper end is rounded; below it shows a marked 
contraction where it joins the nasal duct. The sac is a slit-like opening 
composed of fibrous and elastic tissues, lined with a basal layer of cuboid 
and an inner layer of cylindric cells. In the sac the lining membrane is 
disposed in numerous folds. When distended the diameter of the sac is 
6 or 7 millimetres and its length is 12 millimetres. The nasal cluct extends 
from the lacrimal sac downward from 12 to 14 millimetres, but may be 
prolonged in the nasal mucous membrane and measure 20 or 23 millimetres. 
It opens beneath the inferior turbinated bone by a vertical or oblique slit. 
The nasal duct presents many variations in size. Mr. Henry Power, of 
London, found in 205 European skulls the diameter to average 3.77 
millimetres; and in 181 negro skulls, 4.7 millimetres. The direction of 



Fig. 24.—Probes introduced into tlie eanaliculi to show 
their direction. (Author.) 

(Original drawing by Dr. R. W. Mills.) 


the canal is downward, backward, and outward. The lining membrane of 
the duct is continuous with the conjunctiva above and with the nasal 
mucous membrane below. It is covered with cylindric epithelium. The 
underlying structure is richly provided with lymphoid tissue. A dense net¬ 
work of veins exists between the mucous membrane and the bony walls of 
the nasal duct. 

The Eyelids.—The base of each orbit is closed by soft structures, viz.: 
the eyelids. These are movable folds of skin, strengthened by dense, 
fibrous tissue, and lined internally with mucous membrane. The upper 
lid is the larger and more movable. At the margin of each lid the skin 
and mucous membrane pass into each other, forming two lips on the lid- 
margin. The inner lip is nearly a right angle, the outer is rounded. The 
orifices of Meibomian glands open in front of the posterior inner lip, while 
numerous hair-follicles and cilia are found on the rounded anterior liu. 


ANATOMY OF THE EYE. 


At their free margins the lids are about 2 millimetres in thickness. At 
the outer and inner angles of the eye the lids are united. The junction 
points are called canthi. The interval between the canthi varies, averaerinsr 
about 28 millimetres, and according to its extent gives the appearance 
of a large or a small eye. Throughout the greater part of their extent 
the lids are closely applied to the eyeball, but at the inner cantlms a 
vertical fold of conjunctiva, the plica semilunaris, intervenes. The plica 
is the rudiment of the third eyelid, membrana nictitans, found in many 
animals. Internal to the plica, and filling the inner cantlms, is a reddish 
elevation, the caruncula lacrimalis , which is composed of skin containing 



1, Orbicularis palpebrarum muscle. 2, Skin. 3, Superficial fascia. 4, Waldeyer’s 
glands. 5, Papillae of the conjunctiva. 6, Conjunctiva. 7, Orbicularis palpebrarum 
muscle. 8, Median connective tissue (tarsal plate). 9, Sebaceous gland of eilium. 10, Eye¬ 
lash. 11, Gland of Moll. 12, Duct of Meibomian gland. 13, Meibomian glands. 

modified sweat-glands, sebaceous glands, and hairs. The inner extremity 
of each licl-margin presents a small elevation, in the centre of which is an 
orifice, the punctum lacrimalis, which is the superior extremity of the 
channel for the removal of tears. Above and below, the conjunctiva is 
reflected from the lid on to the globe, the connecting portions being called 
the fornices. The upper fornix is much deeper than the lower. 

Structure of the Lius. —Commencing externally, the skin of the 
lid is thin and lax, and is covered with fine hairs having sebaceous follicles. 
There are also sweat-glands. The glands are imbedded in the subcutaneous 







MODERN OPHTHALMOLOGY. 


26 

areolar tissue, which joins the integument loosely to the orbicularis muscle. 
The orbicularis presents palpebral, orbicular, and ectorbital fibres. The 
palpebral fibres form the sphincter muscle of the eyelids. They arise 
from the internal palpebral ligament (tendo oculi) : a small white cord 
which passes from the inner canthus to the nasal process of the superior 
maxilla. The fibres pass backward, traversing the upper and lower lids, 
and unite at the outer canthus by a cellular raphe, a part.being inserted 
into the external tarsal ligament and malar bone. The orbicularis sends 
fibres to surrounding muscles. It glides easily over the tarsal plate, but 
is attached by slips to the integument. A marginal fasciculus of the 
orbicularis, lying between the eyelashes and posterior lid-margin, has been 
named the muscle of Riolan. On the free margin of each lid is a dark 
line which runs from one extremity to the other —the intermarginal line. 
It corresponds to the anterior part of the tarsus and marks the union of 
the cutaneous and tarsal portions of the lid. 

Beneath the fibres of the orbicularis is a laver of connective tissue, 
the median connective tissue. Beneath it is found the tarsal plate, incor¬ 
rectly known as the tarsal cartilage, which contains no cartilage cells. 
The tarsal plate is a firm, flat body composed of fibrous tissue. The upper 
plate is the larger. They serve to give form to the lids. At the inner 
canthus the tarsi are fixed to the nasal process of the superior maxillary 
bone by the tendo oculi, and externally they pass into the external pal¬ 
pebral ligament. The free margin of the tarsal plate is inseparable from 
the corium of the lid-margin. The orbital margin of each plate passes into 
the tarso-orbital fascia, or septum orbitale. This connects the tarsus to 
the margin of the orbit. In the upper lid the tarso-orbital fascia blends 
with the tendon of the levator palpebra;. When the lids are closed the 
tarsal plates and tarso-orbital fascia form a firm, fibrous covering for the 
eyeball. Imbedded in the tarsal plates are, in the upper lid, about thirty- 
five, and, in the lower, about twenty-four Meibomian glands. They are 
long, acinous glands placed nearly parallel to each other. Each gland 
consists of a vertical duct into which lateral tubular acini open. The 
opaque fatty matter which they contain permits them to be easily seen 
through the conjunctiva. Their ducts open upon the lid-margin. The 
ducts are placed between the conjunctiva behind and the tarsus in front. 
The Meibomian glands secrete the palpebral smegma, which lubricates 
the edge of the lid. The mouths of the ducts are lined with stratified epi¬ 
thelium, while the tubes and glandular recesses have a lining of cubical 
epithelium filled with fatty secretion. Waldeyers glands, known as acino- 
tubular glands, are composed of acini consisting of a basement membrane 
lined with cylindric cells placed around a central lumen. They present 
an oval or round nucleus near their base. Their excretory ducts are lined 
with cylindric epithelium and end in the palpebral conjunctiva. They 
have been wrongly called muciparous glands. At the margin of the lid, 
in front of the muscle of Biolan, are the ducts of the glands df Moll, which 


ANATOMY OF THE EYE. 


are modified sweat-glands resembling the ceruminous glands of the ear. 
The eyelashes are strong hairs arranged in two or three rows along the 
line of union of the conjunctiva with the skin. Those of the upper lid 
are the longer. The hairs curve in an opposite direction in the lids, so 
that their convexities face each other. The life-period of each hair is 
about four months. They are present in all stages of growth. The poste¬ 
rior part of each lid is the conjunctiva, a mucous membrane which covers 
the lid and is reflected on to the eyeball. The palpebral portion is inti¬ 
mately connected with the tarsal plate, while the ocular portion is loosely 
attached to the globe. Hence the impossibility of closing up rents in the 



Fig. 26.—Arteries of the (right) eyelids. (Autiiok.) 

(Original drawing by Du. K. W. Mills ) 

1, Anastomosis between the lacrimal and superficial temporal. 2, Superficial 
temporal. 3, Supra-orbital. 4, Fronto-nasal. 5, Transverse facial. 6, Superior palpe¬ 
bral. 7, Infra-orbital. 8, Inferior palpebral. 9, Facial. 

conjunctiva of the lids, and the ease with which the ocular part of this 
membrane may be lifted up to close losses. Histologically the conjunctiva 
consists of stratified columnar epithelium placed upon a connective-tissue 
matrix. There is in the matrix a certain amount of diffuse adenoid tissue. 
True lymph-follicles are not found in the human conjunctiva (Waldeyer). 
The ocular conjunctiva presents the same structure as the palpebral por¬ 
tion except at the corneal margin, where the epithelium changes from the 
columnar to the stratified squamous type. Lying next to the lid-borders 
is a strip of conjunctiva, about 3 millimetres broad, which likewise is 




28 


MODERN OPHTHALMOLOGY. 


covered with stratified squamous epithelium. It is noteworthy that these 
are the only parts of the conjunctiva free of involvement in trachoma. 

Blood-vessels, Lymphatics, and Nerves of the Lids. — The 
Arteries of the eyelids are the internal and external palpebral, the for¬ 
mer being derived from the ophthalmic and the latter from the lacrimal. 
The vessels pass from the outer and inner angles toward the centre of 
the lid, forming an arch, the tarsal arch, along the edge of the lids. A 
second arch, the external tarsal arch, is found in the upper eyelid, where 
it runs in front of the upper edge of the tarsal plate. The same arrange¬ 
ment is found sometimes in the lower lid. The tarsal arches are joined 
by small anastomosing branches. 



Fig. 27.—Veins of the (left) eyelids. (After Soemmering.) 

1, Branch to the deep temporal vein. 2, Facial vein. S, Supra-orbital. 4, Angular. 5, Branch 
connecting the temporal and facial. 6, Dorsal vein of the nose. 7, Frontal vein. 

The Veins of the eyelids are disposed in two series: the pretarsal 
and the post-tarsal. The former empty into the superficial temporal and 
facial veins, while the latter pass into the ophthalmic vein. 

There are likewise two networks of Lymphatics , which follow the 
corresponding veins. The networks are connected by vessels which 
pierce the tarsi. The lymphatics empty into the submaxillary, pre-auric- 
ular, and parotid , lymphatic glands. The pre-auricular gland is often 
enlarged in gonorrheal ophthalmia. v 

The Nerves of the eyelids are as follows: The levator palpebne is 
supplied by the third and the orbicularis palpebrarum by the facial. The 
sensory nerves are branches of the fifth. 





ANATOMY OF THE EYE. 


29 


ANATOMY OF THE EYEBALL. 

The eyeball is a spheroid, its average measurements in the adult being 
24.3 millimetres in its antero-posterior diameter, 23.G millimetres trans¬ 
versely, and 23.4 millimetres vertically. It presents in front a transparent 
segment of a sphere, the cornea, which forms about one-sixth; and poste¬ 
riorly the opaque sclerotic, forming about five-sixths of the globe. The 
cornea and sclera form the outer, or fibrous, coat of the eye. The second 
coat consists of the iris, ciliary body, and chorioid, which are vascular and 
pigmentary structures. The third, or innermost, coat is the retina, which 
is the expansion of the optic nerve. The nerve enters the globe 3 milli¬ 
metres internal to the posterior pole. The average weight of the eye is 
7.2 grammes; its volume equals about 6 cubic centimetres. At birth its 
weight is 2.2 grammes; and its antero-posterior diameter measures 15.4 
millimetres. Its greatest growth occurs during the first year (Weiss). 



Fig. 28.—Antero-posterior section of the eyeball. (LeveillIs.) 

1, Optic nerve. 2, Sclerotic. 3, Cornea. 4, Spaces of Fontana. 5, Chorioid. 6, Ciliary 
muscle. 7, Ciliary processes. 8, Iris. 9, Retina. 10, Jacob’s membrane. 11, Anterior cham¬ 
ber. 12, Posterior chamber. 13, Pupillary area. 14, Aqueous humor. 15, Hyaloid membrane. 
16, Canal of Stilling. 17, Canal of Petit. 18, Vitreous humor. 19, Capsule of the lens. 
20, Fluid of Morgagni. 21, Lens. 


The anterior and posterior extremities of a sagittal section are called the 
poles of the eye, while a plane dividing the globe into a fore and hind 
half is called the equator. In an adult the equatorial circumference aver¬ 
ages 77.6 millimetres. Within the globe are contained transparent media: 
the vitreous behind, the aqueous in front, and the crystalline lens inter¬ 
mediately. We must now consider these structures seriatim. 

The Fibrous Coat.— Cornea.— This transparent structure, freely sup¬ 
plied with nerves, but devoid of blood-vessels, is fitted into the sclera like 
a watch-glass. It measures 11 millimetres in the vertical, and 12 milli¬ 
metres in the horizontal, diameter. It is thickest at the rim (1.2 milli¬ 
metres), and at its centre measures 0.8 millimetre. The anterior surface 
of the cornea is convex; the posterior surface is concave, and is of greater 
extent than the anterior. The sclera overlaps the cornea, forming a 






30 


MODERN OPHTHALMOLOGY. 


whitish ring called the limbus. Around the corneoscleral junction is a 
slight groove, the sulcus sclerce. The cornea consists of five layers. The 
outermost of these is the epithelium, which is continuous with the epithe¬ 
lium of the conjunctiva, and consists of six or eight layers of cells at its 
centre and more at the periphery. The superficial cells are flat, the cen¬ 
tral ones irregularly polygonal prickle-cells, and the basal layer is colum¬ 
nar. The next layer, the anterior elastic lamina, or Bowman’s layer, is a 
thin, homogeneous lamina, which is thickest in the middle and tapers 
toward the periphery. It measures 0.01 to 0.02 millimetre in thickness. 
Although it presents no corpuscles, this layer does not differ materially 
from the next layer, the true corneal tissue, or substantia propria. This 
comprises the greater part of the cornea, is continuous with the sclera, 
and consists of fibrilke which form about twenty bitndles (lamellae). The 
fibrillae are cemented together, and, while running parallel with the gen- 



Fig. 29.—Section through the human cornea. 

(Bohm and Davidoff.) 

1, Anterior epithelium. 2, Basal cells. S, Bowman’s layer. 4, Substantia 

propria. X 500. 

eral surface of the cornea, they intersect in various ways. It is in this 
layer that the corneal spaces are found. Between the lamellae are irregular 
stellate cell-spaces, which can be demonstrated by staining the tissue with 
nitrate of silver or chlorid of gold. Passing from the spaces, or lacunae, 
are numerous canaliculi, which connect each cell-space with other lacuna?, 
constituting a system of lymph-passages. It is by means of the circulation 
of lymph that the cornea is nourished. These spaces interlace up to the 
corneal border, where they anastomose with the lymphatic vessels of the 
conjunctiva. Contained within the cell-spaces are the corneal corpuscles, 
which are distinguished as “fixed” and “wandering.” The fixed corneal 
corpuscles are anchored to the wall of the lacuna. They do not com¬ 
pletely fill the lacuna, and from the body of the cells protoplasmic proc¬ 
esses pass in every direction into the canaliculi, thus connecting with other 
corpuscles. Since the corpuscles and their processes do not fill the spaces 

















ANATOMY OF THE EYE. 


31 


in which they lie, room is obtained for the circulation of lymph. The 
wandering cells are lymph-cells which have found their way into the 
cornea. In the normal cornea they are few in number; but under patho¬ 
logic conditions they are numerous, escaping from the marginal network 
of blood-vessels. The fourth layer is known as the posterior elastic lamina: 
membrane of Demours or of Dcscemet. This is a homogeneous, elastic layer 
which forms the posterior boundary of the cornea, and, unlike the anterior 
elastic lamina, is sharply separated from the true corneal layer. It resists 
acids and alkalies, but is digested by trypsin. It possesses great resisting 
powers to pathologic processes (and it often prevents perforation of a 
corneal ulcer). In thickness it varies from 0.006 to 0.013 millimetre, 
the thinnest portion being central. At its periphery it breaks up into 
bundles of fibres, to some of which the ciliary muscle is attached. A few 
fibres extend around the angle of the anterior chamber and pass into the 
substance of the iris. They form what is called the ligamentum pectinatum. 



Fig. 30.—Corneal corpuscles of the dog. 

(Bohm and Davidoff.) 

These fibres are more numerous in the eyes of some lower animals (the 
sheep and ox) than in man. Between the fibres passing from the cornea 
to the iris are the spaces of Fontana, which are not well marked in man. 
The endothelium, or fifth layer of the cornea, consists of a single layer of 
flattened six-sided cells which line the posterior surface of Descemet s 
membrane. 

Blood-vessels of the Cornea. —In the adult vertebrates the centre of 
the cornea has no blood-vessels. In man vessels in the form of loops are 
found at the periphery of the cornea, forming a zone from 1 to 1.5 
millimetres broad. These arise from the superficial conjunctival arteries. 

Lymphatics have not been found in the cornea. 

Nerves. —The nerves of the cornea are numerous and are derived from 
the long ciliary nerves via the nasal branch of the ophthalmic division of 
the fifth, the short ciliary nerves of the ciliary ganglion, and a few con¬ 
junctival branches (lacrimal and infratrochlear nerves). These pass into 








MODERN OPHTHALMOLOGY. 


O /v 


the cornea. At a distance of 1 to 2 millimetres from the limbus they lose 
the medullary covering, the axis-cylinders forming a plexus, the funda¬ 
mental plexus , in the anterior part of the substantia propria. From this 
plexus branches pass through Bowman’s membrane, forming a subepithelial 
plexus, from which small varicose fibrils pass among the epithelial cells. 
The primary plexus also gives off branches to the posterior layers of the 
cornea. Some of the finest nerve-fibrils run in the lacuna? and canaliculi, 
where they are in intimate relationship with the corneal corpuscles. A 
connection between these nerve-filaments and the corpuscles has not been 
demonstrated. 

Sclera. —The sclerotic forms the posterior five-sixths of the outer, 
or fibrous, coat of the eye. It is a white, opaque membrane, which gives 
shape to the eye and receives the insertions of the ocular muscles. At its 



Fig. 31.—The iridocorneal angle. (Author.) 

1, Canal of Schlemm. 2, Cornea. S, Ligamentuiu pectination. 4, Spaces of Fontana. 

5, Iris. 

posterior part it is pierced by the optic nerve, and here the sclera is thickest 
(1.1 millimetres). From this point it becomes thin as it is continued 
forward, and is only 0.3 millimetre thick in the anterior part under the 
recti muscles. It becomes thicker (0.6 millimetre) at the insertion of 
the recti tendons. It is composed of white, fibrous tissue, elastic fibres, 
connective-tissue corpuscles, and pigment-cells. The bundles of white, 
fibrous tissue cross at right angles, some being continuations of recti ten¬ 
dons, others following the course of the obliques. The sclera contains few 
blood-vessels, no true lymphatic vessels, and a few nerves derived from 
the ciliary (short and long) nerves. Posteriorly, about 3 millimetres in¬ 
ternal to the antero-posterior axis, the optic nerve pierces the sclera, the 
axis-cylinders entering the eye through the lamina cribrosa. This part will 
be more fully described in connection with the optic nerve. Externally 
the sclera is smooth, and is connected with the conjunctiva by loose con- 


ANATOMY OF THE EYE. 


33 


nective tissue, the episcleral tissue. Internally the sclera presents a num¬ 
ber of fine grooves for lodgment of the ciliary nerves, and a delicate mem¬ 
brane, the lamina fusca , which belongs to the next coat of the eye. Ante¬ 
riorly the sclera is continuous with the cornea, and here the sclera presents 
a beveled edge. The line of union is more peripherally situated internally 
than externally. Hence the sclera overlaps the external layers of the cornea. 

The Vascular Coat.—The vascular and pigmentary coat consists of 
the iris, ciliary body, and chorioid, collectively called the uveal tract. The 
iris forms a curtain, or movable diaphragm, placed in front of the lens 
and suspended in the aqueous humor. It separates the anterior from the 
posterior chamber. The opening in the iris is called the pupil. It is 
almost circular, and is placed slightly to the inner side of the centre of 
the iris. It constantly varies in size during life, and its average diameter 



1, 1, Larger nerves. 2, Plexus beneath Bowman’s layer. 3, S, Terminal twigs 
ascending through the epithelium. 4, Subepithelial plexus. 

is 4 millimetres. The color of the iris varies with the age of the subject 
and the latitude of the country. In the newborn the iris is of a light 
grayish-blue color; later it becomes darker from development of the stromal 
pigment. In northern countries blue and gray irides are the most frequent. 

Structure of the Iris.— The framework of the iris is connective 
tissue, inclosing blood-vessels, nerves, pigment-cells, and muscular fibres. 
The anterior surface, except at the pupillary edge, is uneven, and presents 
crypts and folds. The latter are of two kinds: structural, or permanent, 
folds; and contraction folds, which vary. The anterior layer of the iris 
is an epithelial covering continuous with the fifth layer of the cornea. 
In dark-skinned races these cells contain pigment-granules. The stroma 
of the iris consists of cells and fibres of connective tissue forming a delicate 
mesh in which vessels and nerves are found, as well as pigment-granules. 
The muscular tissue is of the involuntary variety and presents two kinds 









34 


MODERN OPHTHALMOLOGY. 


of fibres: circular and radiating. The circular fibres are on the posterior 
surface of the iris and surround the pupil, forming a circular zone 0.6 
millimetre broad, called the sphincter pupillce. The radial muscular fibres 
—dilator pupillce —pass from the periphery toward the pupil and mingle 
with the circular fibres. The pigment varies in situation in various irides. 
In light-colored eyes the only pigment is that found on the posterior sur¬ 
face of the iris. This layer is absent in albinos. In dark eyes pigment- 
granules are found in the stroma of the iris and in the cells of the anterior 
surface in addition to the posterior layer. The posterior layer, called the 
retinal part of the iris, is made up of pigment-cells and is a continuation 
of the pigmentary layer of the retina, which consists of two layers of pig¬ 
ment. These pass forward in a wavy course to the pupillary edge of the 
iris, where they unite. This layer turns slightly forward, as can be seen 
in Fig. 33. 

10 



Fig. 33.—Radial section of the human iris. (Author.) 


(Original drawing by Dk. Carl Fisch.) 

1, Endothelial layer. 2, Anterior limiting layer. 3, Vascular layer. 4, Posterior 
limiting layer. 5, Pigment layer. 6, Pigment-cell. 7, Capillary. 8, Internal limiting 
membrane. 9, Sphincter pupillse muscle. 10, Pupillary margin. 


The Arteries of the Iris are branches from the long and anterior 
ciliary and the vessels of the ciliary processes. The two long ciliary arteries 
pierce the sclera on each side of the optic nerve, jiass forward between the 
sclera and cliorioid, and divide into branches forming a vascular ring, 
large arterial circle, around the periphery of the iris. From this circle 
small branches pass to the ciliary muscle, while others run toward the 
pupil, around which they form the small arterial circle. The five or six 
anterior ciliary arteries arise from the muscular and lacrimal branches of 
the ophthalmic artery and pierce the sclera just behind the cornea. They 
supply the ciliary processes and join the great arterial circle. In addition 
to these, other small arteries pass from the ciliary processes to the iris. 
The anterior conjunctival arteries are small vessels which become promi¬ 
nent in inflammatory conditions of the conjunctiva. 


ANATOMY OF THE EYE. 


The Veins of the Iris follow the course of the arteries, and end in the 
venae vorticosse. 

The Nerves of the Iris are numerous. They come from the ciliary 
branches of the lenticular ganglion and the long ciliary. There are about 
fifteen of the former. They pierce the sclera around the optic nerve, pass 
forward imbedded in grooves on the inner surface of the sclera, and com¬ 
municate before distribution. They supply the cornea, ciliary muscle, and 



1, Cornea. 2, Sclera. S, Lens. 4, 4, Short posterior ciliary arteries. 5, Long pos¬ 
terior ciliary artery. 6, Anterior ciliary artery and vein. 7, Posterior conjunctival artery 
and vein. 8, Central retinal artery and vein. 9, Vessels of the internal optic sheath. 
10, Vessels of the external optic sheath. 11, Vena vorticosa. 12, Posterior short ciliary 
vein. 13, Branch of short posterior ciliary artery to the optic nerve. Ik, Anastomosis of 
chorioidal vessels with those of optic nerve. 15, Chorio-capillaris. 16, Episcleral branches. 
17, Recurrent chorioidal artery. 18, Large arterial circle of the iris (transverse section). 
19, Vessels of the iris. 20, Ciliary process. 21, Branch of vena vorticosa from the ciliary 
muscle. 22, Branch of anterior ciliary vein from the ciliary muscle. 23, Canal of Schlemm. 
2k, Plexus of the corneal margin. 25, Anterior conjunctival artery and vein. 


iris. In the iris they follow the course of the vessels and form a plexus 
of non-medullated fibres. Fibres from the motor oculi supply the sphincter 
pupilke. The nerve-supply of the dilator fibres is in dispute. Many 
authors state that the dilator is supplied by the sympathetic, but late 
researches show that the dilator fibres do not have tlieir course exclusively 














36 


MODERN OPHTHALMOLOGY. 


through the cervical sympathetic. After excision of the superior cervical 
ganglion and an inch of the sympathetic nerve below it, the author has 
found the pupil reflex to be present. This observation seems to confirm 
the view of those physiologists who hold that dilating fibres pass out 
directly from the brain along the fifth nerve. 

The Ciliary Body includes that portion of the uveal tract placed 
between the termination of the chorio-capillaris, opposite the ora serrata 
behind, and the periphery of the iris in front. It is connected with the 
lens by the zonula of Zinn. The ciliary body is in the shape of a triangular 
prism with its acute angle placed posteriorly and bent upon itself so as 
to form a ring. The uveal tract is closely attached to the fibrous coat at 



Fig. 35.—Injected blood-vessels of iris, ciliary body, and chorioid 
of man. X 7. (Bohm and Davidoff.) 


only two places: one is around the optic-nerve entrance; the other is at 
the point where the tendon of the ciliary muscle is attached to corneo¬ 
scleral tissue. The ciliary body consists of the ciliary muscle, ciliary proc¬ 
esses, ciliary glands, and the usual connective tissue, blood-vessels, and 
nerves. To examine these parts in situ the student should cut away the 
posterior three-fifths of the eye. Looking from within, this part of the 
uveal tract is seen to consist of three parts: the ciliary ring, the ciliary 
processes, and the ciliary muscle. The ciliary muscle, however, cannot be 
seen from behind; it must be examined in an antero-posterior section of 
the globe. The ciliary ring, or orhiculus ciliaris, is a circular tract, 4 
millimetres broad, extending from the ora serrata to the ciliary processes. 

























ANATOMY OF THE EYE. 


37 


In this zone we note, in contradistinction to the chorioid, the absence of 
chorio-capillaris, the presence of muscular fibres connected with the ciliary 
muscle, and the change in the stroma, which here consists of fibrous con- 
nective bundles instead of elastic layers. 

The Ciliary Processes, the most internal part of the uveal tract, 
have the same structural arrangement as the chorioid, being composed of 
pigmented epithelial cells, non-pigmented cylindric cells, homogeneous 
intercellular substance, blood-vessels, and nerves. In the ciliary processes, 
unlike the chorioid, there are no capillaries, the arteries passing directly 



Fig. 3G.—Meridional section of the human ciliary body. 
(After Bohm and Davidoff.) 


1, 2, Conjunctiva. 3, Sclera. 4, Meridional fibres of the ciliary muscle. 5, Ciliary . 
processes. 6, Circular fibres of the ciliary muscle. 7, Iris pigment. 8, Stroma of the 
iris. 9, Canal of Schlemm. 10, Membrane of Descemet. 11, Cornea. 12, Corneal 
epithelium. 

into the veins. The processes present glandular invaginations of the pig¬ 
mented epithelium covering their free surface. These will be described 
elsewhere as the ciliary glands. The ciliary processes are seventy to eighty 
in number. They form the radial vascular folds projecting from the inner 
surface of the ciliary body. After rising to the height of 1 millimetre they 
end at the base of the iris. 

The Ciliary Muscle forms the third zone, or division, of the ciliary 
body. It consists of radial and circular fibres. The former arise from the 
internal surface of the corneoscleral junction, between the canal of 
Schlemm and the anterior chamber. They pass backwaid to the ciliary 










38 


MODERN OPHTHALMOLOGY. 


processes and orbiculus, and constitute the radial ciliary muscle. These 
fibres are attached to the chorioid coat opposite the ciliary processes and 
farther back. Hence the name tensor cliorioidce given by Briicke. The 
size of this muscle varies in different eyes according to the antero-posterior 
diameter. Thus, in the short (hypermetropic) eye the muscle is smaller 
than in the long (myopic) eye, as can be seen in Figs. 38 and 39. 
Many of the shorter radial fibres pass out of their meridional course and 
join the circular fibres, or Muller’s annular muscle. This part of the 
ciliary muscle is placed internal to the longitudinal fibres, and forms a 
circular ring around the periphery of the iris at the base of the ciliary 
processes. 

Ciliary Glands. —In the ciliary body, in front of the ora serrata, are 
small processes, each consisting of a group of cells (Fig. 40). The cells 
are arranged in rings with a central lumen. These glands, according to 
Hicati and Collins, secrete the aqueous humor, and are the seat of patho¬ 
logic changes in serous iridocyclitis. It is proper to state, however, that 



Fig. 37. —Meridional section of human ciliary processes. (Piersol.) 

7, Interstitial connective-tissue stroma, covered by retinal layers {II). i, o, Inner clear and 
outer pigmented layers of cells. /, Fibrous tissue of the processes. 


some observers do not accept this description of the ciliary glands, although 
the researches of Treacher Collins seem to have established their existence. 

The Blood-vessels and Nerves of this part of the eye have been 
described in connection with the iris. 

The Chorioid. —The chorioid is a dark-brown membrane placed 
between the sclera and retina. It is separated from the sclera by a large 
lymph-space traversed by a loose meshwork of fine connective fibres form¬ 
ing the suprachorioid membrane. In this, stellate pigment-cells are found, 
irregularly disposed or in patches; and lymphoid cells also occur here. 
The lymph-space between the chorioid and sclera is lined by endothelial 
cells, and communicates with the capsule of Tenon at the points where the 
vessels and nerves pierce the sclera. The chorioid proper consists of a 
connective-tissue stroma, supporting blood-vessels of different sizes. The 
following layers are noted from without inward: The layer of large vessels ; 
the layer of small vessels, or chorio-capillaris; and the homogeneous layer, 





ANATOMY OF THE EYE. 


39 


or lamina vitrea. The layer of large vessels , also called tunica vasculosa 
Halleri, is composed chiefly of veins closely arranged and often anastomosing. 
The intervascular spaces contain numerous pigment-cells. A surface view 
of this layer, examined in the living eye with tlie ophthalmoscope, shows 
a plexus of bright lines, the vessels resting upon a dark background. This 
is the picture to which the name of tessellated fundus is given. The largest 
vessels of this layer are placed superficially (externally) ; the smallest are 
most internally placed, adjacent to the chorio-capillaris; and the vessels 
of medium size occupy a midway position. Of the largest blood-channels, 
the four vence vorticosce are most prominent. Their tributaries collect 



Fig. 3S.—Section through the ciliary- 
region of an hypermetropic 
eye. (Iwanoff.) 



Fig. 39.—Section through the ciliary 
region of a myopic eye. 
(IWANOFF.) 


blood from the chorioid, ciliary body, and iris. The veins of the chorioid 
are inclosed in lymph-spaces: 'perivascular lymph-sheaths. The capil¬ 
laries of this layer are derived from the terminal branches of the short 
ciliary arteries. The chorio-capillaris, misnamed membrana Ruyschii, 
consists of large-sized capillaries closely placed with very narrow inter¬ 
spaces and no pigment. The lamina vitrea is the most internal layer of 
the chorioid. It supports the pigment-layer of the retina. 

The Tapetum. —In some animals the stroma between the large vessels 
and the chorio-capillaris is fibrous, and, being highly reflective, causes 
their eyes to shine. This layer is called the tapetum. In many of the 





40 


MODERN OPHTHALMOLOGY. 


domestic animals it consists of wavy bundles of connective tissue. In the 
carnivora the reflex is due to the presence of plate-like cells containing 
innumerable small crystals. 


L- ; . 

/. 


HM 

tC * , 

%-f #*#*> 


* % 

. 

s-y if t*:;<>■ 

- » ' 


* ! jlE 


<5» j* 




■: *4 

* 







*•« 


;** . 

•* ... * ■ 


» *. e «*«»,* 

* * * # > t»* • 

, ^ ph 

« V '**' * 


in 


«’ / *v * 

-t*. . ■- 


AS • * * 


« $ 


* e 


© 




, «L* 
•X * ! 

’&*l i ; 

*«-#V 




v 


Fig. 40.—Bleached section showing glands of the ciliary body. 
X 300. (Treacher Collins.) 


Anatomy of the Corneoscleral Junction. —The fourth layer of 
the cornea, near the corneoscleral junction, divides into a number of fibres. 
Some of these give attachment to the ciliary muscle, while others pass 
around the angle of the anterior chamber to join the iris and form the 



Fig. 41.—Vertical section of the chorioid. (Boiim and Davidoff.) 

1, Lamina vitrea. 2, Chorio-capillaris. 3, Layer of large vessels. 

4, Siiprachorioidea. 5, Sclera. X 130. 

ligamentum pectinatum iridis. The fibres passing to the iris are covered 
with endothelial cells continued from the membrane of Descemet; but 
these cells do not cover the interspaces between the bundles of fibres, and 
for this reason the fluid in the anterior chamber communicates freely with 







ANATOMY OF THE EYE. 


41 


the interspaces. The spaces in this sponge-like tissue are known as the 
spaces of Fontana, and are larger in the eyes of the ox and sheep than in 
the human eye. A similar, but larger space, the canal of Schlemm, is 
found within the sclera at its junction with the cornea. It is a flattened 
circular channel, elliptic in section, and is often double or treble in parts 
of its course. It communicates with Fontana’s spaces, and by these with 
the aqueous chamber. It also is connected with the veins in the anterior 
part of the sclera. Hence, the aqueous humor can leave the eyeball via 
the spaces of Fontana, the canal of Schlemm, and the scleral veins. 
Schwalbe found that spaces and veins were filled with a colored fluid 
which had been injected into the anterior chamber. The canal of Schlemm 
must be regarded as a venous channel, although many anatomists’ believe 
that it is a lymph-channel. It certainly is the drainage apparatus of the 
eye. The canal of Schlemm is visible in living eyes possessing a thin 
sclera (found in young girls). Under oblique illumination it appears as 
a dark line concentric with the corneal margin. The dark color indicates 
that the canal in life contains blood (Fuchs). 

Iridocorneal Angle. —• The point of junction of the iris, cornea, 
sclera, and ciliary muscle forms an important part of the eye, both 
anatomically and pathologically. The angle of the anterior chamber, as 
this part is sometimes called, becomes blocked in glaucoma. 


THE OPTIC NERVE, RETINA, LENS, AND VITREOUS. 

The Optic Nerve. —This nerve, derived from the primary optic vesicle 
of the embryo, is regarded as a part of the brain. It is divisible into 
cranial, orbital, and ocular portions. The nerve is about 5 centimetres 
long, of which 3 centimetres are in the orbit, 1 centimetre is in the optic 
canal, and 1 centimetre is intracranial. Its width is 5 millimetres. The 
nerve ends anteriorly in the retina. The nerves of opposite sides are con¬ 
nected by the optic commissure. Behind the commissure they are named 
the optic tracts. Each optic tract has two origins: one from the stratum 
opticum of the corpora quadrigemina, the other from the optic thalamus. 
Passing backward the optic tract ends in ganglion-cells of the pulvinar, 
anterior quadrigeminal, and external geniculate bodies. From these gan- 
glion-cells fibres, named optic radiations, pass backward to end in ganglion- 
cells of the cortex of the posterior part of the occipital lobes. The optic 
fibres are distributed to the occipital lobe, including its mesial surface, 
the cuneus. The cuneus is bounded by the parieto-occipital fissure above 
and in front, and by the calcarine fissure below. It is this region, the 
cuneus and the parts around the calcarine fissure, which is the visual area 
of the cerebrum. Each optic tract winds around the corresponding crus 
cerebri and passes inward and forward to join its fellow in forming the 
commissure. 

The optic tract and commissure are composed of medullated nerve-fibres 


42 


MODERN OPHTHALMOLOGY. 


bound together by neuroglia. They have no neurilemma. Their blood- 
supply comes from small vessels supplying the front part of the brain and 
pia mater. The optic nerves are composed of medullary fibres, neuroglia, 
and blood-vessels surrounded by pia mater. The orbital portion of the 
optic nerve is covered in addition by the arachnoid and dura mater. 
Lymph-spaces exist in the nerve and between its coverings in the orbit. 

The Retina. —The expansion of the optic nerve within the eye is a 
delicate membrane called the retina. External to it is the chorioid, and 
internally it rests on the hyaloid membrane of the vitreous body. The 
retina extends from the entrance of the optic nerve to the pupillary margin 
of the iris, and is divisible into three zones: (1) the optic part, reaching 
forward to an irregular, serrated margin situated just behind the ciliary 
processes (ora serrata) ; (2) the ciliary part, extending from the ora 

serrata to the ciliary margin of the iris; (3) the iridal part, covering the 
posterior surface of the iris. The optic part, alone sensitive to light, is 



/. of Rolando 
intrapanetal fissure 


f. of Sylvius 
parallel fissure 


Fig. 42.—Diagram of occipital region of right cerebral hemispheres. 
A, from inner, B, from outer, aspect. 


divisible into: (1) an outer, or neuroepithelial, layer; and (2) an inner, 
or cerebral, layer. Each of these is microscopically separable into several 
layers. 

The ciliary and iridal parts of the retina contain no nerve-elements, 
and are simply pigment layers. The retina varies in thickness from the 
macula (0.5 millimetre) to the ora serrata (0.1 millimetre). Its inner 
surface is smooth; its outer surface is adherent to the chorioid. The 
inner surface presents three points of interest: the macula lutea, the fovea 
centralis, and the porus opticus. The first, known as the yellow spot, is 
in the axis of the globe. It is elliptic in shape, and measures from 1 to 2 
millimetres in diameter. In its centre is a depression, the fovea centralis, 
0.2 to 0.4 millimetre in diameter. Here the structure is much changed, 
as will be explained later. About 3 millimetres to the nasal side, and 1 
millimetre below the yellow spot, is the porus opticus, the place where the 
optic nerve pierces the retina and expands into its inner layer. The optic 



ANATOMY OF THE EYE. 


43 


disc forms a slight elevation, colliculus nervi optici. In its centre is a 
physiologic excavation, the point from which the retinal vessels branch. 
The color of the retina is a light pink in the fresh eye; if kept in a dark 
place for some minutes before removal, it is a purple-red. Exposure to 
sunlight bleaches it. Boll discovered the retinal purple which Kuhne 
named rhodopsin. It is found in all parts of the retina except the macula, 
fovea, and ora serrata. After death the retina becomes opaque. 

Layers of the Retina. —Microscopic study of the retina has claimed 
the attention of a host of observers from the time of Heinrich Muller to 
the present day. Recent researches have resulted in a classification of the 
retinal layers much different from that of the early writers. The later 
anatomists, particularly Ramon y Cajal, using the Golgi stain, give the 
following layers:— 


1. Pigment epithelium layer. 

2. Layer of rods and cones. 

3. Granules of the nerve-cells. 

4. Outer plexiform layer. 

5. Layer of horizontal cells. 


6. Layer of bipolar cells. 

7. Layer of amakrine cells. 

8. Inner plexiform layer. 

9. Ganglion-cell layer. 

10. Layer of nerve-fibres. 



Fig. 43.—The macula near the fovea centralis. X 80. 

(Photomicrograph by Da. G. A. Dixon of a section by Du. J. E. Weeks.) 


These are shown diagrammatically in Fig. 45, after Golgi’s method. 

For the purpose of histologic description, the following designations 
are most conveniently used:— 

f 1. Pigment epithelium. 

T xx ! 2. Laver of rods and cones. 

I. Neuron - 

3. Membrana limitans externa. 

[_ 4. Outer nuclear layer and layer of Henle’s fibres. 

5. Outer plexiform layer. 

II. Neuron { G. Inner nuclear layer. 

7. Inner plexiform layer. 

f 8. Layer of ganglion cells. 

III. Neuron J 9. Layer of nerve-fibres. 

j 10. Membrana limitans interna. 

Optic Part of the Retina. —As already mentioned, this part of 
the retina is divided into two layers, the neuroepithelial and the cerebral, 
each of which consists of a number of laminae; so that, including the pig¬ 
mentary layer, this part is composed of ten different strata. Besides the 


44 


MODERN OPHTHALMOLOGY. 


nervous epithelial elements, the retina contains supporting structures (not 
of connective-tissue origin), the most important of which are the radial, 
or Muller, fibres. They run from the inner surface to the layer of rods 
and cones. Their distal end is conically enlarged, and the bases of these 
cones join together to form the so-called membrana limitans interna. Their 
nuclei lie within the inner granular layer; along their whole course they 
send out processes in all directions. There are in the outer reticular layer 
other supportive cells, which are called concentric cells; near the entrance 
of the optic nerve glia-cells are found. To these supportive structures, too, 
belong fibres which arise from the membrana limitans externa, and basket¬ 
like surround the bases of the rods and cones. 



Fig. 44.—Hexagonal cells from the pigment layer of the retina 
of a rabbit. (Author.) 


(Photomicrograph by Du. H. P. Wells.) 


Cerebral Layer. —The layer of nerve-fibres consists of non-medul- 
lated axis-cylinders arranged in bundles. They are most numerous at the 
site of entrance of the optic nerve, and run radially to the ora serrata (see 
macula lutea). For the most part they are centripetal fibres derived from 
the ganglionic layer, but there are centrifugal fibres coming from cerebral 
ganglionic cells, which end free in this layer. 

The layer of ganglion-cells (ganglion nervi optici) is a single layer 
of large multipolar cells, sending an undivided process (axis-cylinder) 
to the layer of nerve-fibres and dendritic processes toward the inner retic¬ 
ular layer, where they form a dense network with the corresponding proc¬ 
esses of other ganglion-cells. 


ANATOMY OF THE EYE. 


45 


This inner reticular (plexiform) layer is formed by a very fine net¬ 
work ol supportive tissue, in which processes of all the ganglion-cells of 
the retina are imbedded. 

1 he elements of the inner granular layer are of verjt different types. 
Its innermost layer is formed by large multipolar ganglion-cells, which 
send processes into the inner plexiform layer. Many of them emit also 



Fig. 45.—Diagram of the structure of the human retina according 
to Golgi’s method. (Greeff. ) 


1, Pigment epithelium layer. //, Rods and cones. Ill, Granules of the visual cells. 

IV, Outer plexiform layer. V, Layer of horizontal cells. VI, Layer of bipolar cells. VII, 

Layer of amakmne cells. VIII, Inner plexiform layer. IX, Ganglion-cell layer. X, Layer of 
nerve-fibres. 1, Diffuse amakrine cell. 2, Diffuse ganglion-cell. 3, Centrifugal nerve-fibre. 

4, Amakrine association fibres. 5, Neuroglia-cells. 6, Muller’s radial fibres. 

an axis-cylinder to the layer of nerve-fibres. The remaining strata of this 
layer are mostly characterized by the presence of small bipolar cells (gan¬ 
glion retinas) which show a centrifugal process ramifying in the inner 
plexiform layer and another one reaching to the outer reticular layer, 
where it divides in a maze of fine fibrillfe. All of the bipolar cells are 



































































46 


MODERN OPHTHALMOLOGY. 


provided with a process that penetrates between the visual cells and ends 
with a little thickening at the level of the membrana limitans externa. The 
most external part of the layer is taken up by large and small spider-shaped 
cells, from each of which an axis-cylinder is sent to the layer of nerve- 
fibres, while numerous fine processes enter into the outer plexiform layer. 

The outer plexiform layer, like the inner layer, is a network of fibres 
of the supporting substance, which contains the process just mentioned. 
In it, too, the concentric cells are found, as well as some displaced ganglion- 
cells, which belong to the ganglion retinas. 

Neuroepithelial Layer. —This lamina contains the rod- and the 
cone- cells, which are peculiar by the fact that their nuclei lie in the lower 
half of the cells, while the rest of the cell perforates the membrana limitans 
externa, thus seemingly appearing separated from the lower half. This 
peculiarity gives rise to the appearance of tw T o layers, the outer granular 
layer (the nuclei of these cells) and the layer of the rods and cones. The 
rods and cones consist of two halves, an outer homogeneous part (cylindric 
in the rods and conic in the cones), and an inner granular part. In the 
cones the inner part is thick and swollen. The nuclei of the rod-cells show 
two or three transverse stria?, and the inner parts of rods and cones contain 
a peculiar filamentous apparatus. The number of rods exceeds that of the 
cones considerably. They are arranged in regular intervals. Those por¬ 
tions of these visual cells which are in contact with the outer plexiform 
layer show a characteristic striation (the fibrous layer of Henle). 

The pigmentary lamella finally is formed by a single layer of hexag¬ 
onal pigmented cells. Their sides toward the chorioidea are pigment-free 
and contain the nuclei. 

This arrangement of the retinal layers is somewhat changed within 
the macula lutea and the fovea centralis. Delicate optic fibres proceed 
directly from the entrance of the optic nerve to the nearest medial portion 
of the macula, while all the shorter fibres pursue a convex course and unite 
at the periphery of the macula. At the macula the layer of ganglion-cells 
consists, instead of a single one, of eight to nine layers of cells. The 
inner granular layer, too, is considerably increased in thickness. The 
neuroepithelium consists only of cone-cells; so that here the latter alone 
form the layer of Henle. 

Toward the fovea the layers of the retina become gradually thin. The 
layer of nerve-fibres almost disappears and the layers of the cerebral por¬ 
tion confluesce to a thin lamina; so that in the centre the fovea consists 

\ 

only of the neuroepithelium. 

Nearing the ora serrata one after another the different layers become 
thinner and finally disappear; only the radial fibres persist. 

Ciliary and Iridal Parts of the Eetina.— The former consists of 
a single layer of elongated cylindric cells, which originates from the union 
between the outer and inner granular layer. Their surface is covered by 
a cuticula, while on the outside they are connected with the pigment layer. 


ANATOMY OF THE EYE. 


47 


In the iridal part we distinguish two layers: an anterior, with spindle- 
shaped, and a posterior, with polygonal, pigment-cells. The posterior 
surface is covered with a thin cuticula, the limitans iridis, which is derived 
from the membrana limitans interna retinae. 

As to the connection of the nervous elements of the retina, the cells 
of the ganglion nervi optici, as well as the star-shaped cells of the inner 
nuclear layer, furnish the centripetal optic fibres, while the centrifugal 
fibres end free in the inner nuclear layer. The cells of the ganglion retinae 
do not possess axis-cylinders. Their connection with the rest of the nerv¬ 
ous elements is effected by means of the nervous plexus in the inner and 
outer plexiform layer. The visual cells are the ones sensitive to light. 

The Optic Commissure. —This, called also the chiasma, is formed by 
the union of the optic tracts in their course forward. It rests on the optic 
groove of the sphenoid bone. Above, it is attached to the brain, and is sepa¬ 
rated from the third ventricle by a gray membrane, the lamina cinerea. 
External to the chiasma is an area pierced by a number of small arteries, 
the anterior perforated spot. Behind it is the posterior perforated spot and 
a conic membranous process, the infundibulum, connected with the pitui¬ 
tary body. The chiasma consists of the true and the accessory tracts. The 
true tracts are of two kinds: the crossing fibres from the nasal sides of 
the retinas, which occupy the centre, and the uncrossed fibres from the 
temporal sides of the retinae, which occupy lateral positions. The fibres 
originating in the macula lutea have been so carefully traced of late years 
as to call for the naming of a third class of fibres, the “macular fascicle.” 
Some of these decussate, while others do not. The accessory fibres are 
those of Meynert and Van Gudden. They are fibres arising from the 
internal geniculate body of one side, which, passing forward to the optic 
chiasma, traverse its posterior border, and then bend backward to end in 
the internal geniculate body of the other side. They play no part in vision. 
While the commissure of Van Gudden lies within the posterior angle of 
the chiasma itself, and is only with difficulty differentiated from the 
decussated optic fibres, the fibres of Meynert are distinctly separated from 
the chiasma by a thin layer of gray substance. Their course, too, runs 
parallel to the posterior angle of the chiasma. 

Crossing of the Optic Fibres. —Each optic nerve consists of two 
bundles of fibres: an outer and an inner. The outer, consisting of fibres 
coming from the outer half of the retina, do not cross, but pass to the 
same side of the brain; the inner, derived from the inner half of the 
retina, cross to the opposite side of the cerebrum and end in the pulvinar, 
anterior quadrigeminate, and external geniculate bodies. Thus, the right 
pulvinar, right anterior quadrigeminate, and external geniculate bodies 
receive fibres from the nasal half of the left eye and the temporal half of 
the right eye. Thus, the decussation of the chiasma is not complete, but 
is a semidecussation. Owing to the manner of crossing, the right halves 
of both retinae and the left halves of the visual fields belong to the right 


48 


MODERN OPHTHALMOLOGY. 


optic tract, while the left halves of both retinae and the right halves of 
both visual fields belong to the left tract. Objects situated to the left of 
the observer become known to him by .excitation of the right occipital cortex, 
and vice versa. The fact of semidecussation of the optic nerves permits 
the explanation of half-sight (hemiopia). 

Orbital Portion of the Optic Nerve. —The orbital part of the 
nerve is a firm, white, rounded cord, 3 centimetres in length and 5 milli¬ 
metres in diameter. It does not pass straight to the eyeball, but forms 
an S-shaped bend, thus permitting an extensive range of movement of the 
globe. In passing through the optic canal the nerve lies on the outer 
side of the ophthalmic artery. In the canal the nerve is liable to injury 
from fracture of the canal-walls or from growths or suppuration in the 
sphenoidal sinus. 

The nerve-trurik consists of over 40,000 medullated fibres supported 
by a framework of neuroglia. The fibres are disposed in parallel bundles. 



Fig. 46.—Photomicrograph of the optic chiasma, showing 
decussation of the nerve-fibres. (Autiiok.) 

(Photographed by Dlt. Carl Fisch.) 

which anastomose with each other. Lymph-channels are found between 
the outer surface of a bundle and the inner surface of the septa. The 
nerve-slieatlis in the orbit are three: dural, pial, and arachnoidal. The 
sheaths are continuous with the cerebral membranes posteriorly and with 
the sclera in front. The dura forms a thick, loose covering, and is lined 
with endothelium. Between it and the inner sheath is the intervaginal 
space. The arachnoidal sheath is a delicate layer attached to the dura and 
pia by trabeculae of connective tissue. It divides the intervaginal space 
into an outer, subdural, and an inner, subarachnoidal space, which connect 
with the intracranial spaces of the same name. The walls of these spaces are 
covered with endothelium and the spaces are regarded as lymph-channels. 
The presence of these spaces explains the occurrence of swelling of the 
head of the optic nerve (papillitis) in certain diseases of the brain. The 
blood-vessels pass from the pia into the nerve; in addition, the anterior 
part of the nerve transmits the arteria centralis retina}, which is a branch 


ANATOMY OF THE EYE. 


49 


of the ophthalmic and enters the nerve from 10 to 12 millimetres behind 
the eyeball. The central vein empties into the superior ophthalmic vein or 
into the cavernous sinus. Both artery and vein run in the axis of the nerve 
to reach the retina. Within the eyeball they are called the central retinal 
artery and vein. 

The optic nerve enters the eyeball through a funnel-shaped opening 
in the sclera, about 3 millimetres to the nasal side of the optic axis and 
1 millimetre below the horizontal meridian. On entering the globe the 
sheaths and septa are merged into the sclera and the medullary coverings are 
lost. Hence only the bare axis-cylinders enter the eyeball, and the nerve 
becomes transparent and of less diameter as it'terminates in the optic papilla. 
At the level of the sclera is a network of connective tissue called the lamina 
cribrosa. It marks the depth that the observer can see with the ophthal- 


- 1 

- 2 
- 3 


Fig. 47.—Transverse section of orbital part of the optic nerve behind 
the entrance of the central vessels. (After Merkel.) 

The shaded area marks the position of the papillo-macular fibres. 1, Dura. 

2, Intervaginal space. 3, Pia. 

moscope. The point of entrance of the optic nerve into the globe is the 
weakest part of the eyeball. It is this part which first gives way when intra¬ 
ocular tension becomes increased. A circle of blood-vessels surrounding the 
nerve-head makes this one of the most vascular parts of the eye, and com¬ 
municates with chorioid, sclera, optic sheath, and retina. It is called the 
circle of Zinn or of Haller. 

RADIATIONS OF THE NERVES OF THE EYE. 

Optic Nerve.—The peripheral neuron of this nerve is imbedded alto¬ 
gether in the ganglion-cell layer of the retina, while the central neuron 
originates in the internal layers. The nerve-fibres proceed along the optic 






50 


MODERN OPHTHALMOLOGY. 


nerve toward the central organ. In the chiasma these fibres partially 
decussate, so that those of the left halves of the retince are distributed to 
the left tract and those of the right halves to the right optic tract. The 
optic tracts consequently contain fibres of both optic nerves. It is asserted 
that long and short tracts exist, of which the long tracts proceed to the 
lateral geniculate bodies and from there to the posterior limb of the internal 
capsule. Continuing to the occipital lobes, they form the optic radiation. 
The short tracts, predominating in numbers, ramify terminally around the 
ganglion-cells in the corpora quadrigemina anteriora, the corpora geniculata 
lateralia, and in the pulvinar of the thalamus. A third, or central cortical 
neuron, from these ganglion-cell fibres passes out to the radiation in the 
posterior limb of the internal capsule and to the cuneus in the occipital 
region. 



Fig. 48.—Transverse section of the orbital part of the optic 
nerve in front of the entrance of the central 
vessels. (After Merkel.) 

The shaded area marks the position of the papillo-macular fibres. 


About the meaning of another class of fibres starting from the corpora 
quadrigemina anteriora, and after decussation going to the retina (centrif¬ 
ugal fibres), nothing certain is known. 

Oculomotor Nerve .— 1 The central neuron of this nerve is most likely 
to be looked for in the gyrus angularis. Running through the base of the 
internal capsule, it reappears as a part of Spitzer's bundle. It then under¬ 
goes decussation in the motor oculi nucleus of the opposite side (beneath 
the aqueduct of Sylvius). Here its terminal ramification takes place. 
From the ganglion-cells of this nucleus the roots of the motor oculi are 
sent out, which, after a partial decussation, run to the eye as the trunk of 
the motor oculi nerves. 



ANATOMY OF THE EYE. 


51 


Patheticus Nerve. —The central neuron is identical in its course with 
that of the preceding nerve. Decussating, its fibres come to their terminal 
ramification in the trochlear nucleus behind the nucleus of the oculomo- 
torius, below the corpora quadrigemina posteriora. Behind the latter, after 
decussation, the peripheral neuron passes out as the trochlear nerve. 

Abducens Nerve.— The ramification of its central neuron, which pur¬ 
sues a course like that of the foregoing nerves, takes place after decussation 
in the abducens nucleus under the floor of the fourth ventricle. The 
abducens nerve (as a peripheral neuron) takes its origin from the ganglion- 
cells of this nucleus and takes its course through the posterior part of the 
pons. 1 

THE CRYSTALLINE LENS. 

This structure, which is an important part of the accommodative ap¬ 
paratus of the eye, is a transparent biconvex body which rests in the patellar 
fossa of the vitreous behind, is connected laterally with supporting fibres of 
the zonula of Zinn, and in front forms a support for the iris. The rounded 
edge of the lens is separated from the ciliary processes by a space of 0.5 
millimetre. The lens presents for examination a central substance, the lens 
proper, and a covering, the lens-capsule. The lens is unique among optical 
apparatus in that it has the property of changing its form, thus producing 
greater or less refraction of light. 

Dimensions of the Lens. —The following table, giving the diameters 
of the lenses of a series of fetal eyes, is by Treacher Collins:— 


Age. 

Number op Eyes 
Examined. 

Antero-Posterior 

Diameter. 

Transverse Diameter. 

4th 

month 

3 

CO 

c>i 

millimetres 

3.3 millimetres 

5tli 

66 

1 

3.5 

66 

4.0 

6th 

66 

4 

3.8 

66 

4.5 

7th 

tc 

8 

4.0 

66 

5.0 

9th 

66 

3 

4.3 

66 

5.75 


One of the measurements of the adult lens is given incorrectly in 
numerous works on anatomy and ophthalmology, the antero-posterior 
diameter calculated by Helmholtz (3.7 millimetres) having been often 
copied. As Priestley Smith has shown, this diameter is 4.5 to 5 milli¬ 
metres, and in old people is sometimes 6 millimetres or more. Trans¬ 
versely, the lens measures about 9 millimetres. Its weight is 0.20 gramme; 
its volume is 0.25 cubic centimetre; its specific gravity is 1.121. Its ante¬ 
rior radius of curvature is 10 millimetres for far and 6 millimetres for near 


1 For a full consideration of the neuronic architecture of the visual apparatus the reader can consult 
the classic work of Dr. St. Bernheimer, of Innsbruck : “Die Wurzelgebiete der Augennerven, ihre Verbiu- 
dungen und lhr Anschluss an die Gehirnrinde,” in the new Graefe-Saemisch “Handbuch der Augen- 
heilkunde,” Leipzig, 1900. A chart explanatory of Dr. Bernheimer’s researches has been published by 
Dr. Louis Strieker, of Cincinnati, O., in the Journal of the American Medical Association, March 2, 1901. 












52 


MODERN OPHTHALMOLOGY. 


vision. Its anterior pole is 2.3 millimetres behind the cornea. Chemically 
the lens consists of 60 per cent, water, 35 per cent, soluble and 2.5 per 
cent, insoluble albuminoids, 2 per cent, fat with traces of cholesterin, and 
0.5 per cent. ash. 

Structure of the Lens.—The lens consists of a soft, compressible, non- 
vascular material which is colorless in youth, but yellowish and opalescent 



Fig. 49.—Isolated lens-fibres. (After J. Arnold.) 

in old age. In the early period of life it possesses a uniform consistency, 
but in the aged a central hard portion, or nucleus, is distinguishable from 
the peripheral, or cortical, part, which is soft. Nutrition of the lens is ac¬ 
complished by the intercellular movement of nutritive fluids. When divested 
of its capsule, the lens shows on its anterior and posterior surfaces numerous 
faint, white lines, which radiate from the poles. In the fetal lens there are 
three of these lines (radii lentis) ; in the adult they are more numerous. 


Fig. 50.—Transverse section of lens-fibres. 


(After J. Arnold.) 


They mark the points of junction of the ends of the lens-fibres. The lens- 
fibres are cells which look like bands of ribbon on the flat, and show hexag¬ 
onal outlines when cut transversely. The superficial fibres are broader 
and thicker than the central ones. The fibres 'are 0.005 millimetre broad. 
They adhere by their edges, which often are serrated in such a way as to 
leave very minute intercellular spaces for the passage of fluid. The fibres 
pass in a curved direction in such a way that no fibre reaches from pole to 







































ANATOMY OF THE EYE. 


53 




pole. Those fibres, for example, which begin at the posterior pole end on 
the anterior surface near the margin. Between the capsule and the lens- 
substance is found an albuminous material which during life is probably 


Fig. 51.—Anterior surface of the lens of an adult. 

(After J. Arnold.) 

semifluid, but which after death rapidly liquefies. It is called liquor Mor¬ 
gagni. The growth of the lens, after its primary development, comes from 
the addition of layers of new lens-fibres derived from the cells of the epi¬ 
thelium of the anterior capsule. When incised the lens is seen to be com- 

1 2 


Fig. 52/—Marginal whorl of the lens, showing the transition of 
the epithelium into lens-fibres. (Schultze.) 

1, Capsule. 2, Epithelium of the capsule. S, Layers of the zonula. 4, Zonula. 

• 

posed of lamellse which can be lifted up and which resemble the layers of 
an onion. Section of the marginal portion of the lens shows the lens- 
whorl of 0. Becker (Fig. 52), which is due to variations in the axes of 
developing lens-fibres. 






















54 


MODERN OPHTHALMOLOGY. 


The Lens-capsule is a transparent, elastic membrane which incloses 
the lens proper and affords attachment to the zonula. The anterior sur¬ 
face of the capsule is about 0.015 millimetre thick, while the posterior is 
only half this thickness. The inner surface of the front part of the capsule 
shows a single layer of cubical, polygonal, nucleated cells (epithelium of 
the lens-capsule). Near the margin of the lens these cells become converted 
into young lens-fibres. 

The Zonula is the suspensory apparatus by which the lens is held in 
position. It also is an important agent in accommodation, since, when 
the ciliary muscle contracts, the zonula relaxes and permits the lens to 
become more convex. To obtain a clear idea of the zonula, the student 
should harden an eye in formalin (5 per cent.), cut away the posterior 
half of the globe, and remove the vitreous; then he should remove the 
cornea and adjacent part of the sclera and cut the iris close to its ciliary 
border. The zonula is seen, lying in the space between the margin of the 



Fig. 53.—Epithelium of the inner surface of the anterior 
capsule. (Schultze.) 

lens and the ciliary processes (Fig. 54), appearing as numerous radiating 
fibres. The zonula thus formed is a fibrous, reticulated structure, which 
extends from the ciliary part of the retina to the lens. That part of the 
zonula which passes from the ciliary body to the lens is known as the 
suspensory ligament. When the ligament is torn away, some of the pig¬ 
ment of the ciliary body adheres to it. 


THE VITREOUS BODY. 

The greater part of the eyeball, comprising the space between the 
lens and retina, is filled with a transparent, jelly-like substance called the 
vitreous humor. It is inclosed in a delicate capsule called the hyaloid 
membrane. The vitreous body presents anteriorly a central depression, the 
patellar fossa, in which the lens rests. Posteriorly it is perforated by a 
lymph-space, the hyaloid canal (canal of Cloquet or of Stilling), which 
runs from the optic disc to the lens and marks the position of the hyaloid 



PLATE II, 

Normal Fundus Dculi, 


Sn» .;•>■s$Ss&" '■ 

•• • %r. >-% > /Jfti .* 










.'i.f,' 










Fig, 1,—Narmal Fundus 
(averagB tint), 


j m*S&iW 

£,'3- 


tJJ&M&S ■!• w? 


r ty t #' : y£ g/ Wj ■ ■ v>V* 

* 1 ?'**r y. V?> r-> iSS'fe $8*?/* ’ -W £& - •«' 

■'.-' r ' i ■ *. v * ' -• £.* *& 


ISiS&k' 




ss^ 


fitipflllm 

i-'fW' 

pigF 

iaIJfeifeSw 

Jlfy.'•JfaCgT'Vl 

w 


rJ, 




§-m 'Jp, 

JSfo'Sjv.fiMfcflk 


Fig, 2,—Normal Fundus 
of a HrunettB, 



V? 




jt aTiLPi 

■ilnaD ai/han'T IfirrioK 
y? •; i:\ QFffrH ’J v,u yf v. 

ii- a transparent el.> ■ •• ontbfr’.ne 

- rack . nt v -j; 

ihou 0.013 olTm; tie .thn-C, while 
: . - The inner surface of the front j . 

of cubical, polygonal, nue.tea.teil ec 
\< r ti.-*: margin of the ic • these c* i. ; 


-Uti ■?.- 




> an iinporfcani agent in accon.m.• 

r • Urdu r P Ui U’- 

scrtumV SaixiraW— t 

■ ; a - obtr !- y.iiaffl dp^aWi-j • 

k-rt ,ra ■ vo in formalin (5 per cer .:, « 
and- remove 'the vitreous j rb« >t ; 
M-onf ;'art <>>. 'he a and cut t • 


■loses 
: sur- 
rior is 

v.apsule 

Uam of 
eon verted 


,e v- 


is is held in 
‘•a sine**, when 

* , i) its the lens to 
>.-■ ul.i, the student 
away the posterior 
should remove the 
close to its c:diary 


D 1 1 


ula is see , lying in the space iy the margin of the 



' > ■ • ■ • ; ■- - t- . inti-rmr 


1 nd the <: Ur • <•>■< 

(■-«- The stoiutl; v 
tends from I'i'.e cih >r 


Wj 




pi aso: hjnm a a 
id. of the eili.txv ; 




«c|* (Schui.tze.). 

^ Fig. 54), appearing as numerous adiatmg 
.\ Too as, reticulated structure, which 
y.'vt of the rot na to the lens. That part of the 
*.i ; v; . !,.»? i-o.lv to tire lens is known as the 

acfuKTI .faarinVf—, Si .tjrj 

BDsu'cTTfe 3 -iV^ awa 3> ot Vi,; pig- 

1 : ' • ; ' ■- I . i 


THE ViTPt*v>.i;$ BODY, 

The greater part of tu-• eyeball, comprising the space between-the. 

■ 

' ".••'•us humor. T - iiu:Jo*\d m a C>i - m•• capsule called the hyaloid 
• -ubrane. The \ : lr ' <fy p-r-esents a.-' '-io-v a central depression, the 
,t- tar fossa, in wi •< • - -- h-ns rests. l‘> ■■■• ' e-ly it is perforated by a 

■voh-spaee, the hymmo cm mi (canal of Cloquet or of Stilling), which 
■*! *. from the optic r the 'em and marks the position of the hyaloid 


PLATE 2 








•> 


ANATOMY OF THE EYE. 


55 



artery of intra-uterine life. The vitreous forms a support for the retina, 
and this function is of greater importance than its action in refraction. 
Its index of refraction is low (1.336). Chemically the vitreous consists 
of 98.5 per cent, water, with traces of solids, salts, extractives, proteids, 
and nucleo-albumin. The fetal vitreous shows a network of interlacing 
fibrillae, and is regarded as an embryonal form of connective tissue. 

The hyaloid membrane, whose existence has been denied by such emi¬ 
nent observers as Henle, Merkel, and Iwanoff, forms a delicate investment 
over the whole vitreous body. These structures possess no blood-vessels 
in adult life, and are nourished by transudation from the vessels of the 
retina and the ciliary body. 


Fig. 54.— Dissection to show the zonula. (After Schultze.) 

1, Lens. 2, Cut surface of the iris. 3, Ciliary processes. 4, Chorioid. 5, Zonula. 

In the substance of the vitreous different forms of corpuscles are found, 
some vacuolated, others not. From them processes project which show 
bead-like enlargements. 

THE OCULAR LYMPH=SPACES. 

In the conjunctiva lymphatic vessels are present. Elsewhere in the 
ocular structures their places are taken by lymph-spaces, which form two 
systems: an anterior and a posterior. 

Lymph from the anterior segment of the globe collects in the anterior 
and posterior .chambers, whence it passes through the ligamentum pecti- 












56 


MODERN OPHTHALMOLOGY. 


natum into the canal of Schlemm. From this channel it passes into the 
anterior ciliary veins. 

The posterior lymph-spaces are: (1) the hyaloid canal; (2) the 
perichorioidal space, situated between the chorioid and sclera, and com¬ 
municating by means of 'spaces around the venae vorticosae with (3) the 
space of Tenon, which lies between the sclera and Tenon’s capsule. From 
these points lymph collects and passes into (4) the intervaginal space 
found between the sheaths of the optic nerve and (5) the supravaginal 
space which surrounds the sheaths of the same nerve. Lymph-spaces sur- 



Fig. 55.—Diagram of lymph-spaces of the eyeball. (After Fuchs.) 

1, Anterior chamber. 2, Posterior chamber. 3, Canal of Schlemm. 4, Hyaloid canal. 
5, Anterior ciliary vein. 6, Continuation of Tenon’s capsule on the ocular tendons. 7, Lymph- 
space around vena vorticosa. 8, Perichorioidal space. 9, Supravaginal space. 10, Inter¬ 
vaginal space. 


round the retinal veins and capillaries and probably the arteries. Occlu¬ 
sion of the anterior lymph-spaces is one of the phenomena of glaucoma; 
nothing is known concerning occlusion of the posterior spaces. 


THE NORMAL FUNDUS OCULI. 

The optic is the only nerve which can be examined during the life of 
the patient without dissection. By means of the ophthalmoscope the in¬ 
terior of the eye can be studied. The parts of chief interest in the fundus 
are the optic disc, the blood-vessels, the macula lutea, and the chorioid. 





























































PLuH.TE III, 


Normal P'undus Qoull. 


Fig, 1,—Normal Fund as with Unusual 
Arrangement of Eloot!-vessels, 




• I .I TTMS 


i 


5G 


wtom ini' tli 

anterior « 

r - . 

oeHft'T- 

; 

f<$ttnd b>' 


■ilu.j! i 311 L tiifi lamtvW v « . 

ir i-h;.; ond :t passes into the 

: #'l) ; '.H hyaloid < rial; (2) the 
.* fi '’si oi l and - ora, and eotn- 

4j ')■; ] i ,0 v< rife vorticose with ( 3 ) .he 
. , ; am! '! ■ con’s gaps ale. From 

of the on'. •• acre fm-i • o) the supravaginal 
A .-atli .•'3111'.' nerve. ! ^ymph-apaces sur- 


• , » 

i£02imU :!irw -mba sT. lertraVT--,!: ,gn 
.alBaaa'T-tealH la Jnyma^jstTA 


its? 

(A 







jg iHa^v irn of Uropfi-spaces of the oy> >a (After Icchs.) 

. 4nt. '.-:«r I'.iarv v«»a. #, Gmrtin«ati<* of Touch’* capsule on the o-.alftr tendons, f, Lymph- 
y’ ( a.t: aiwrnd voua v^rtlwwu S Penchoriokial space. a. Sujpravaginal space. 10, Inter- 
vaginal apace. 

.antldXA ns to eirfimrT—,S .gfH 

• und the retinal veins and capillaries and probably the arteries. 0< elu¬ 
sion of the anterior lymph-spaces is one of the phenomena of glaucoma; 
nothing is known concerning occlusion of the posterior spaces. 



THE NORMAL FUNDUS OCULI. 

s ’ 

The optic is the only nerve which can be examined during the life of 
the patient without di>s< etioB. By means of the ophihahnoscop' The in¬ 
terior of the eye can be suMied. The parts of chief interest in the t undus 
are the optic disc, the bloou -vessels, the macula lutea, and the chorioid. 
















PLATE 3 









ANATOMY OF THE EYE. 


The Optic Disc. —This is situated about 3 millimetres to the nasal side 
of the posterior pole of the eye, and is the point of entry of the optic nerve 
into the retina. It is often called the head of the optic nerve. It measures 
from 1.4 to 1.7 millimetres in diameter and is generally circular or ellip¬ 
soidal in shape. In the astigmatic eye the optic disc often appears oval 
or ellipsoidal when in reality it is round. Owing to the magnification when 
the ophthalmoscope is used, the papilla appears to be from 9 to 18 milli¬ 
metres in diameter. Near its centre is a depression, the physiologic excava¬ 
tion, which marks the divergence of nerve-fibres. The excavation is funnel- 
shaped, the base being anterior. A trace of the hyaloid artery of fetal life 
is occasionally seen here as a thread of connective tissue running from the 
papilla into the vitreous. Surrounding the papilla are two rings: an 
inner, due to exposure of the sclera, is whitish, and is called the scleral 
ring; and an outer one, due to the showing of chorioidal pigment, is named 
the chorioidal ring. At the bottom of the excavation a few dark spots are 
seen, from the gray stippling of the lamina cribrosa. In color the papilla 



Fig. 56.—The norma] fundus of the right eye. (Henle.) 

is grayish pink or reddish, and stands cut- in marked contrast to the red¬ 
dish yellow of the remaining parts of the fundus. The color of the papilla 
varies with the age and complexion of the individual, the color of the. 
surrounding parts of the fundus, and with the illumination used. A bluish 
discoloration of the disc has been observed as a congenital abnormality. A 
more common anomaly is the presence of opaque nerve-fibres, which con¬ 
dition is due to the fact that the medullary covering of the axis-cylinders 
exists in the fibre-layer of the retina. In such a case the fundus shows a 
patch of a brilliant white color extending out from the disc (Fig. 2, Plate 
IV). Generally the white area is in contact with the disc. It rarely oc¬ 
curs that the opaque fibres are found at a great distance from the nerve- 
head or that they occupy a large area of the fundus. The physiologic cup 
or depression may occupy a large part of the nerve-head, but never extends 
to the scleral ring. Under normal conditions many variations are seen in 
the size and depth of the cup and in the arrangement of the blood-vessels. 





58 


MODERN OPHTHALMOLOGY. 


The Blood-vessels are the central artery and vein. They run in the 
nerve-fibre layer of the retina, and, although often presenting variations, 
are of sufficiently regular distribution to justify the naming of the follow¬ 
ing branches: Superior and inferior nasal, superior and inferior temporal, 
and macular. The retinal arteries are terminal arteries, each arteriole 
supplying its own territory without anastomosis. Hence, if a branch is 
obstructed by an embolus, its territory becomes ischemic and vision is lost. 
(While this statement is true for almost all cases, in a few instances of 
embolism of the central artery anastomoses have occurred.) The middle 
of the fovea centralis has no blood-vessels. 



Fig. 57.—Diagram of the retinal vessels of the left eye. 

1 , Superior temporal artery. 2 , Superior temporal vein. 3 , Superior nasal vein. 

4, Superior nasal artery. 5 , Inferior nasal vein. 6 , Inferior nasal artery. 7, Inferior temporal 
vein. 8 , Inferior temporal artery. 9 , Macula lutea. 10 , Macular veins. 

While it is often stated that the retinal vessels can be seen on oph¬ 
thalmoscopic examination, as a fact it is the column of blood, and not the 
vessel-wall, which is visible. In the larger retinal vessels the blood-column 
in the arteries is brighter than that in the veins. In the smaller branches 
this difference is less marked. The brighter color of the arteries is due 
to the presence of a central streak of light, which is less marked in the 
veins. The cause of this light-streak is not definitely known. The retinal 
arteries never pulsate under normal conditions. (To this statement, which 
is true for the vast majority of individuals, exceptions must be made, since 
Jaeger, von Graefe, Donders, and other competent observers have seen 
spontaneous arterial pulsation in normal eyes.) The reason for non¬ 
pulsation in the retinal arteries is this: the normal intra-ocular tension 











plate' itr. 

Normal Fundus Dculi, 



Die b? ' 


> _ y 

dluaD submit mmia'VI 

» ?.v: •:■• and \o:b They run in the 
, ■' oi.U'ii presenting ■variations, 

a‘- ■ <»: just if v ;he naming of the follow- 
trior and inferior temporal, 
terminal arteries, each arteriole 
■ , ; /mastorooBie. Hence, if a branch is 

.« • becomes ischemic and vision is lost. 

• •■;•< • tor almost all eases, in a few v im ranc-es of 
i -.••o/r- anastomoses have v< err -o ) The middle 
u‘‘ i • : 'M'x|-veS;0‘ls-. 



Fig. 57.—Diagram of ths retina! vessels of the ieft eye. 

1. Superior temporal i.rterf. t, Superior i >rm '/in. Superior ntvsal vein, 
i. *upei iov nasal artery. Inferior nasal v jj«. c. Inferior .;,ts>aV arkfjr. 7, Inferior temporal 
>om, S, Inferior temporal artery. 9, ??;.;..la lutea. Jo, >1 icular reins. 


While it is often stated that tic r< ’mil vessels can be seen on oph¬ 
thalmoscopic examination, as a fact d is the column of blood, and not die 
-- v-aih • deli is vistffe* T® h ■ un:n 

in the arteVies is brighter than that in the veins. In the small *r branches 
Mas difference is less marked. The b: '•voter color of the art.-vies is due 
to the presence of a central streak of ! ghr. which is less marked in the 
v ci.m-. The cause of this light-streak is nor d-Taitelv known. Tin? retinal 
arteries never pulsate under normal conditions. (To this statement, which 
true for the vast major t . of individua - lions must Iv .cade, since 
Jaeger, von Graefe, I lender?. and other e-n* o< mt observers leave seen 
iem s arterial pulsation in norma! eyes. ) The reason ffw nou- 
pubation in the retinal arbu - t s this, the a< ’-nnai intra-ocular tension 







PLATE 4 





ANATOMY OF THE EYE. 


59 


is sufficient to overcome the diastole of the heart. Arterial pulsation may 
be produced easily in the normal eye by pressure on the globe. Whenever 
a disproportion exists between intra-ocular and intra-arterial pressure, 
arterial pulsation occurs. A enous pulsation occurs spontaneously in from 
60 to 75 per cent, of normal eyes. 

Besides the blood-vessels enumerated above, it is necessary to mention 
the cilioretinal vessels. These are commonly small, solitary vessels which 
arise from the circle of Haller, and emerge at the temporal border of the 
disc. Such a vessel may come from the central vessel in the substance of 
the nerve, and may be of larger size. Generally it supplies blood to a small 
area between the disc and macula.' Cilioretinal vessels are present in from 
10 to 16 per cent, of normal eyes. Their presence has been known to 
permit a portion of the retina to retain its functions in cases of embolism 
of the central retinal artery. Most cilioretinal vessels are arteries. 



Fig. 5S.—Injected blood-vessels of the macular region. 
(Bohm and Davidoff.) 

1, Capillary loops of the macular region. 2, Fovea centralis—no vessels. 


Having described the usual arrangement of the blood-vessels, it is 
necessary to mention some • of the unusual appearances found in normal 
e}^es. Twisting of a vein and artery often occurs; but it rarely happens 
that an artery crosses an artery, or a vein crosses a vein. Anastomoses are 
very rare anomalies, and occur on the optic disc. Instances of bifurcating 
arteries and veins are shown in several ophthalmoscopic atlases. Although 
the retinal vessels do not pursue a straight course, their tortuosity is sub¬ 
ject to much variation. A rare anomaly is the presence of a projecting 
loop. In Lawford’s case a vein formed a loop, each end of which disap¬ 
peared in the disc. An unusual arrangement of vessels observed by the 
author is shown in Fig. 1, Plate III. Here incomplete twisting of the 
superior temporal artery and vein is seen; cilioretinal arteries are present 
at the nasal side of the disc; and the arterial supply of the lower half of 
the retina comes from a large trunk, which divides into four branches at 
the lower margin of the disc. The case was that of a boy, aged 12 years, 
whose vision was normal after the correction of a small amount of hyper- 


GO 


MODERN OPHTHALMOLOGY. 


metropia. The presence of a persistent hyaloid artery, as a small loop 
projecting into the vitreous humor, is occasionally observed. Its persistence 
as a blood-carrving vessel is a rare abnormality. 

Perivascular Lymph-channels.—His (18G5) was the first anatomist 
to demonstrate the existence of perivascular lymph-spaces in the retina. 
Schwalbe, Norris, and others, by injecting fluid beneath the pial sheath 
of the optic nerve, have filled the spaces around the retinal veins and capil¬ 
laries. Analogous sjuaces surround the retinal arteries. 

The Macula Lutea.—Situated about 3 millimetres to the outer side 
of the optic-nerve head, and slightly below the horizontal meridian, is a 
spot darker than the surrounding retina and apparently devoid of blood¬ 
vessels. This is the macula lutea (yellow spot). It is the area of greatest 
visual acuity. The centre of the macula presents the foveal reflex, while 
the periphery shows a whitish, glistening ring, or halo, knoAvn as the 
macular reflex. It is strange that no two ophthalmic writers agree as to 
the color and appearance of a part of the retina so accessible to examination 
as the macula, and that the errors of forty years ago should appear in 
modern text-books. Many writers have portrayed the macula as oval, with 
its long diameter placed transversely. Schmidt-Pimpler described it as 
anatomically circular, but oplithalmoscopically oval. Panas and Mauthner 
saw it as a brilliantly silvered ring. Power spoke of it as “a soft, whitish 
line”; and Landolt described it as “a bright, oval line, sometimes glistening, 
with a red floor and intensely red, almost black, centre, the dark point in 
the centre being hardly ever absent.” These differences in appearance are 
doubtless due to several causes: the difference in methods of examination; 
in the age, complexion, and refraction of different individuals; and varia¬ 
tions in the distribution of pigment. Johnson states that, when observed 
in a certain way, the macular ring in its whole circumference can be seen 
in every person under thirty-five years of age, and frequently in older sub¬ 
jects. If the illumination is lowered, reflection from the fundus decreases 
more rapidly than from the macula, until a moment arrives when the ring 
appears. He asserts that the macular ring is invariably circular, and 
probably corresponds to the extreme limit of the macular region. When 
observed as an oval, the appearance is due to distortion produced by the 
lens and mirror. When examined carefully by the direct method of oph¬ 
thalmoscopy the macula is always round. In elderly persons it can be 
recognized, although with more difficulty than in the young, by its darker 
color and by the absence of vessels. 

There are several forms of macular rings. Johnson states that the 
most common is a bright, scintillating reflex resembling shot-silk, very 
marked in dark eyes, scarcely visible in' fair ones, and best seen with feeble 
illumination. This ring is supposed to be due partly to reflection from 
Muller’s fibres, where they expand into the internal limiting membrane, 
partly to the fibrous sheaths of the vessels which lift up the retina over- 
lying them. A second form of ring is a radiating circle of grayish-white 


FLUTE V. 


Normal Fundus □ cull i Macular and FcvBal Raflaxss, (Johnson.) 


Fig. 1, —Ordinary Type of Macular 
Ring. The fcvsa is a dull-red circular 
spot, Five "Crick” dots surround it, 
English, bay aged eighteen years. 


Fig. 3. — Macular Region of a 
Native African Bay, Aged Sixteen 
Tears, from the Lower Congo Re¬ 
gion. 


Fig. 5.—A Long "Comet-flare " from 
a Boy. Aged Eight Tears, with Light 
Flaxen Hair. Vision = §. 


Fig. 7,—Macular and Foveal Rings. 
Spanish girl with black hair and dark- 
brown irides, HypBrmBtropia = 1 D. 
Vision = 


Fig, 2.—Marked Macular Ring with. 
Foveal and also a Secondary Ring, 
An English bey, aged eleven years,with 
brown iridES. Hypennetrupla = 2 E. 
Vision = 


Fig, 4. —Fovea of an Adult (Man, 
Aged Twenty-seven 'fears) with Light- 
Brown Hair, Th.afovr.ais round and of 
a buff color. The e ye vas emmetropic, 

Vision = §, 


Fig, 3,—The Macula nf an Albino 
(Woman, Aged Twenty-one Tears). 
The chorioidal vessels arB prom¬ 
inent, Tha fovea is an ill-dafined 
reddish spot, 


Fig, B. — Macular Region of a 
Woman, Aged Thirty-six Tears.with 
Brown Hair, Gray Eyes, and Fail 1 
Complexion. ThB whole fundus is 
stippled with black specks like 
grains at pepper, Vision = f. 


.If 3.THJ.H 

(. wDbwhdTj) .aaxBPte H In eirn'T 


(LOGY. 


mis i Pl'xJrSfe 

. . , reserved. Its persistency 


di.hw jjnWH TsIunsM fi3'2fxEM — ,S ,gn 
.grrtH yfabnasaS a oa iA be. a Isavn'T 
riHTO,arB3Yaavaia bagH ,Yarfbailga3 a A 
,CI S = BlaO’tJ’SiirxBCYKf .aabixt xiwdtc! 

.f *i OOtfilV 


the first anatomist 
aces in the retina, 
i oath, the pial sheath 


•jjfc 

ile 

lie 


,xiaM) t'-irbA jib lo bbygT—,*• igCT 
-JjlgU rfjiw (ai>33 Y nB\rsa-x1n.awT bag£S 
lo baa bicLHci si jf-avul sxlT? .itsH .awcVS 
3iqa'03mrna bew axe sriT .tc^ciatp/g a 

.{ = nclal'y 


; ■ Jolt'd' 1 ribed it as 1 . ,r 
r and intensely >ed. a* 
>e,ug hardly ever ahtwet 
; ae to several canses: tin 
, complexion, and >>>f Action of 

■ ■■ distribution of ’ : ;■ •" 

' 

erson under thittv-flv* \ vmww of 


ibIbubM in agyO? i- 

TBlrxdTiu' tiaT-Ilirb b si .aavcl aiiT . gruH 
<1 bm-Ji'iCB ?-*o-6 " xalTE “ bvH Wcqs 

i».‘-*nv%' the horizontal merit \ is a 
tin.; and apparently devoid of blood- 
■1 low spot). It is the area o' gn 
u-ula presents the fovea 1 reflex, 
boning ring, or halo, known a 
e two ophthalmic writers agree as to 
the retina so accessible to examination 
o f,.; « \ ./e .!■- •: . si niid appear in 

b la xiblgaK TCEcrtirM'— 'Swfei't' ' 11 
n-E3lxi3 begA; ,'fiiS ne.-COH s-t.ObW 
■sH ogan3 iawcJ a sLI tn^ai .aiaaY 

v 1 «!;»? <m*. .c-jg 

}' - nvki: <' :t as “u soft, whitish 

nes glistening. 


so met 
re. tin 

fc.*<*8 ill 


dark point in 


; at* 




ppea; 
exai i 
s; ai 
ihtn 


11C€ 


are 
on: 


■’iimterence 
frequent’ 


anirilA n a in Bl^rasM stfT—.3 .gCt 
.(s'ibuY aan-YtiiaWT'' fa's git 1 ^BmoXSt) 
-OTa'iq b'eb sl?.eF»sYrJaibtrni»il j rjIT 
baaneb-At os at aavc! . hxIT .iHBCi 

■ ■ ’ rtS^ei is jjtiqa deibbst 

, ids ; ■ • . 

• ■ ' as an oval, ihe n pe ir n 

riiiuofrco[>y the macula is aiway 
•eeuized^ although with more <J: 
..<• and by the absence of vemi 
:;:■" several forms ef 


M>s*i?rv cd 
be seen 
m older sub- 

l fviitYl fnG flllldfifi ( 

ntoii M arari-iMEroa'* gnoa A—.fi gCt 
tttfeld XUiw 1 ai£iaY: txfgitS SsgJft .v^bH aiif 

■■ ,.b if the macnlar region. When 
.y ho to distortion produced by the 
•fed bv the direct method of onh- 

V V 

uvi'i. In elderly persons it -an be 
h • th-n in the young, bv its. darker 


•aculai 


n -•fcates that, the 
ig shot-silk, very 


a In jaalgaST ufilirasM-fl.B ,glt 'V it Wig I'Cm \ ' - , 1 ■: 

dnw,2^B3yi xtB-yi x TpiTbpap. 1 picnL3W _j ( , jVtP vo H: tl 4* -cldc 

TtB'l baa irwoTO: ' n ' -ix^fc bqa aisxl j£qbW ilttw lyig rii’.taeq2 

fci subbiiCBloittri3gTnnifil3i.3lqfntjn' ’bCCl '.,Q f'i. -BiiioalBiznatnrH 

?*4 eaJfjp^ ,..+ 0 the imeni d iin.w hie’lmfttfhfflne, 

— nolteitr .isqqaq to mitag . , 

wt \ to the fibrous sheaths of ihe vessels which lilt, up the retina over- 


A'second form 


is a radiating du< 


of grayish-white 


them. 





PLATE 5 




















ANATOMY OF THE EYE. 


61 


lustre, the radii being directed toward the fovea and resembling nerve- 
fibres. The appearance is supposed to be due to a partial translucency of 
the nerve-fibres. The third form of ring can be seen with the brightest 
illumination as a whitish or golden ring of metallic lustre, oval in shape 
by indirect ophthalmoscopy, but circular when seen by the direct method. 
It is narrower than the other two rings. 

The foveal reflex is found in the centre of the macula as a very small 
ring, or as a circular or horseshoe-shaped spot of light, or as a “comet- 
flare.'” It is due to reflection of the edge of the fovea. 

The Chorioid.—While each ocular tunic contributes something to the 
ophthalmoscopic picture, the chief part must be credited to the chorioid. 
Light reflected from the mirror of the ophthalmoscope passes through the 
transparent part of the retina to the pigment epithelium, and is partly 
absorbed, partly reflected. Although the pigment layer belongs embrv- 
ologically to the retina, it generally adheres to the retinal surface of the 
chorioid, and is accredited ophthalmoscopically to the latter tunic. The 
brightness of the fundus picture depends on the amount of pigment. The 
greater the pigment, the greater the absorption of light and the darker the 
fundus picture. In the negro and the native of India the fundus is of a 
brownish, brown-red, or slate color, while in the Anglo-Saxon, and par¬ 
ticularly in blondes, it is of a bright-red color. If the pigment layer is 
very thin, the chorioidal vessels are correspondingly exposed and are seen 
as a network of large, flat vessels, without a light-streak, between which 
are spaces of light or darker color. They are seen best in albinos. It is gen¬ 
erally impossible to differentiate between the chorioidal arteries and veins, 
although at the equatorial region the latter converge to form the venre 
vorticosEe. In brunettes the vessels appear as “light streams separated by 
dark islands,” because the spaces are more deeply colored than the vessels. 

The Sclerotic, which may be spoken of as the panel on which the 
fundus picture is painted, is commonly invisible, being covered by the 
nearty opaque chorioid. Yet it is probable that in all eyes some light 
passes through the chorioid, and thus the sclera has some influence on the 
ophthalmoscopic picture, serving to make it lighter. In albinos the sclera 
appears as a white surface between the chorioidal vessels. It is best seen 
where the chorioid is absent, as in coloboma, or pathologically as a result 
of destruction of the retina and chorioid. 


CHAPTER III. 

PHYSIOLOGY OF VISION. 


The sense of sight is the most highly developed and differentiated 
of the special senses. The eye is for the purpose of receiving rays of light 
which are focused on the retina, where they are changed into a stimulus 
of nerve-fibres. These stimuli are transmitted to the brain via the optic 
nerve. It is necessary to study: (1) the mechanism of the formation of 
retinal images, and (2) the events following the formation of images. 


MECHANISM OF THE FORMATION OF IMAGES. 

Refraction.—In order to understand how an image is formed on the 
retina, it is necessary to mention a few optical principles with reference 



particularly to the laws of refraction of light by transparent bodies bounded 
by curved surfaces. The simplest form of dioptric apparatus consists of 
two media of different refractive indices separated by a spherical surface. 
The optical properties of such an apparatus depend on (1) the curvature 
of the surface, and (2) the refractive powers of the media. Such a simple 
optical system is shown in Fig. 59. 

The line P-R represents a curved surface separating media of different 
refractive power, the less being on the left. The line O-A, falling per¬ 
pendicular to the surface at 3, passes through the centre (6) of the sphere 
with whose surface we are dealing. This line, O-A, is the optic axis. All 
lines which cut the surface normally, such as O-A, C-Y, and U-I, undergo 
no refraction. They continue in straight lines and cross at 6, which is 
the nodal point. All other rays passing from a medium of less to one of 
greater density are refracted. x411 lines lying in the first medium and 
parallel to the optic axis will be bent so as to meet at M, which is the 
principal posterior (or second) focus. On the optic axis, in the first 
medium, is an important point, B. Rays of light passing from B, such 
as B-I-T, are so refracted that they become parallel to the optic axis. B 
(62) 










PHYSIOLOGY OF VISION. 


63 


is called the principal anterior (or first) focus. The point where the optic 
axis cuts the surface is called the principal point. The above-mentioned 
points—posterior and anterior foci, the nodal point, and the principal 
point—are called the cardinal points of an optical system. 

It is necessary to know the effect of a biconvex lens upon light, because 
the dioptric media of the human eye equal such a lens. The action of a 


1 2 



biconvex lens can be appreciated by reference to Fig. 60. In the illustra¬ 
tion at the left (1), C and G mark the centres of curvature. The line con¬ 
necting them is the chief axis, and the centre of this line is the optical 
centre of the lens. Bays passing through the optical centre of a lens are 
unbent. The illustration at the right (2) shows that rays falling on a 



E 


Fig. 61.—Action of a convex lens on rays of light proceeding from 
a point within the focus. 


lens parallel with its principal axis, G-l J , are collected on the opposite 
side at a point called the principal focus. Conversely, rays which diverge 
from the focus after passing through the lens emerge as parallel lines. Fig. 
61 shows that rays which pass from a point within the focus (h) after pass¬ 
ing through the lens leave it less divergent, but do not come to a focus 


















64 


MODERN OPHTHALMOLOGY. 


Convex lenses form real and inverted images of such objects as are 
placed beyond the focal point of the lens. The action of a biconvex lens 
is explained in Fig. 62. The arrow M-P, placed upright before a biconvex 
lens, gives an inverted image (p-ni) on the opposite side of the lens. 

To form an image on the retina it is necessary that rays of light shall 
be bent. The amount of bending or refraction of a ray of light depends 
on: (1) the radius of curvature of the refracting surface; and (2) the 
difference in the refractive indices of the medium from which the ray 
comes and that into which it passes. The smaller the radius of curvature 
and the greater the difference of refractive index, the more the ray will 
be bent. The refractive media of the eye are the cornea, aqueous humor, 
lens, and vitreous humor. The following table gives the radii of curvature 
of the refracting surfaces, the refractive indices of the dioptric media, and 
other data needed in the study of refraction in the human eye:— 






P 

Fig. 62.—The image formed by a biconvex lens. 


In Accommodation for 

Near Vision. 

7.8 mm. 

6.0 “ 

5.5 “ 


3.2 mm. 

7.2 “ 

4.0 “ 

14.6 “ 
21.S mm. 

1.337 

1,335 Vitreous humor. 1,3365 

1.3365 Lens (average). 1,437 


Radius of 
curvature of 


Cornea . 

Anterior surface of the lens. 
Posterior surface of the lens. 


Distance 

between 


-> 


Anterior surface of the cornea and 
the anterior surface of the lens... 
Anterior surface of the cornea and 
the posterior surface of the lens.. 
Anterior and posterior surface of the 

lens . 

Posterior surface of the lens and 


Far Vision. 

7.8 mm. 

10.0 “ 

6.0 “ 


3.6 mm. 


i .i 


3.6 


retina . 14.6 “ 

Antero-posterior diameter of the eye along the axis.. 21.8 mm. 

Refractive Indices. 

1 000 Cornea. 


Air . 

Water . 

Aqueous humor 





















PHYSIOLOGY OF VISION. 


65 


The Reduced Eye. —In order to simplify the problem connected with 
the formation of retinal images, physiologists have constructed schematic 
and reduced eyes. The measurements given below are for the reduced eye 
of Listing:—- 


Radius of curvature of the single refracting surface. 5.1 mm. 

Index of refraction of the single refracting surface. 1,35 

Antero-posterior diameter of the reduced eye.20.0 mm. 

Distance of the single refracting surface behind the anterior surface 

of the cornea. 1.8 “ 

Distance of the nodal point from the anterior surface. 5.0 “ 

Distance of the nodal point from the principal focus (retina).15.0 


The Visual Angle. —If the position of the centre of curvature of the 
single refracting surface of the reduced eye— i.e., the nodal point—is 
known, the position of the retinal image of an object can be found by 
drawing straight lines from the circumference of the object through the 



Fig. 63.—Diagram of the reduced eye. 

S, The single spheric refracting surface 1.8 mm. behind the anterior surface of the 
cornea. I, The nodal point, 5 mm. behind S. G, The principal focus (on the retina), 20 
mm. behind 8. The cornea and lens are represented by dotted lines in the positions they 
should occupy. 

nodal point to the retina. These lines cut the refracting surface at right 
angles and pass through the single refracting surface without bending. 
The retinal image is found to be inverted. The size of the image is in 
proportion to the angle made by the lines drawn from the periphery of 
the object to the nodal point. This angle is called the visual angle (Fig. 
64). Objects seen under the same visual angle have retinal images of the 
same size. Acuteness of vision is measured by the smallest angle within 
which an object is visible. The normal eye recognizes letters five times as 
long as they are broad when they are at such distance that they strike the 
eye at an angle of five minutes. 

The Retinal Image can be demonstrated in the enucleated eye of an 
albino rabbit and in the human eye. The image differs from the object 
in size and in the relative arrangement of its parts. Its size is generally 
smaller than that of the object, regardless of the distance, and its position 
is reversed, the lower part of the image representing the upper part of the 
object, and the left side of the image corresponding to the right side of 

5 


I 

















6G 


MODERN OPHTHALMOLOGY. 


the object. In visual judgment, however, as will be mentioned later, the 
retinal image is reinverted. 

The size ot the retinal image can be calculated, if the size of the object 
and its distance from the nodal point are known. The formula for deter¬ 
mining the size is this:— 

Size of retinal j _ size of object X distance of the image from the nodal point 

image j distance of the object from the nodal point 

Accommodation. —By this term is meant the power possessed by the 
eye of seeing objects distinctly at different distances. The agents concerned 
in accommodation are the lens and ciliary muscle. The eye has often been 
compared to the camera of the photographer: the dioptric media equal the 
lens, the pigment of the retina and chorioid makes the chamber dark, the 



Fig. 64.—Diagram to show that the visual angle and size of the retinal 
image vary with the distance of the object from the eye. 

The image of S-B is seen at os, under the angle g; and the image of T-C is seen at i-.w, 

under the angle Ma. 


retina is the sensitive plate, the iris regulates the amount of light, and the 
focus is obtained by the action of the ciliary muscle on the lens. In the 
camera the focus is obtained by moving the sensitive plate nearer to or 
farther from the lens. In the human eye the retina occupies a fixed posi¬ 
tion, while the focusing is accomplished by alterations in the curvature 
of the lens. As regards the exact mechanism of accommodation authorities 
differ, there being two principal theories. Helmholtz held that, when the 
ciliary muscle contracts, the chorioid and ciliary processes are brought 
forward, the suspensory ligament of the lens is relaxed, and the lens—by 
virtue of its elasticity—becomes more convex. Tscherning has advanced 
the view that accommodation does not depend upon slackening of the 
zonula of Zinn, but on its tension, which is brought about by the ciliary 
muscle, by which the periphery of the lens becomes flattened and the curve 
of its surface assumes an hyperboloid form. Tscherning states that he has 
actually produced this change by making traction on the zonula in the 







PHYSIOLOGY OF YISION. 


67 


eyes of animals from which the cornea had been removed. Schoen has 
also attacked the Helmholtz theory of accommodation. Which of these 
hypotheses is correct must be decided by future investigations. 

That a change takes place in the pupillary part of the lens during 
accommodation is demonstrated by the alterations occurring in the reflexes 
called the Purkin je-Sanson images. These are catoptric images (i.e., re¬ 
flected) from the cornea and anterior and posterior surfaces of the lens. 
They can be understood by a study of Pig. 65. Let light fall on the eye 
through a triangular opening. Three images will be seen: the brightest, 
an erect virtual image, is from the anterior (convex) surface of the cornea; 
another erect virtual image, larger, but less bright, is from the anterior 
(convex) surface of the lens ; and a small inverted real image is from the 
(concave) posterior boundary of the lens. The second image is inter¬ 
mediate in position between the other two. If the eye is accommodated 
for a near point, the corneal image is unchanged. The middle image 


12 3 12 3 



A B 


Fig. 65.-—Purkinje-Sanson images. 

A, In the absence of accommodation. B, In accommodation. 1, Reflection from the cornea, 2, From 
the anterior surface of the lens. $, From the posterior surface of the lens. 

becomes smaller and approaches the corneal image, showing the curvature 
of the anterior surface of the lens to be increased. A slight change occurs 
in the third image. By means of special apparatus Helmholtz was able 
to determine that in maximum accommodation the radius of curvature of 
the anterior surface of the lens is 6 millimetres as compared with 10 milli¬ 
metres when the eye is at rest. Another change which occurs in accom¬ 
modation is a slight sinking of the lens, which is due to its weight (Heine). 

The nervous mechanism of accommodation is under the control of 
the will. The ciliary muscle is governed by fibres which can be traced 
through the short ciliary nerves and ciliary ganglion, along the third nerve, 
to a centre located (in dogs) at the front end of the aqueduct of Sylvius. 
Stimulation of this centre, or of the third nerve, or of the short ciliary 
nerves leads to contraction of the ciliary muscle and accommodation for 
near objects. 

In recording accommodation certain terms are used which must now 


68 


MODERN OPHTHALMOLOGY. 


be explained. The most distant point of distinct vision is called the far 
point (punctum remotum) = R. The nearest point at which small print 
can be read is named the near point (punctum proximum) — P. The 
amount of accommodative effort of which the eye is capable is called 
the amplitude of accommodation = A. In the normal eye the ampli¬ 
tude of accommodation is expressed by the formula: A = P — R, in 
which P and Pi, are expressed in dioptres (a dioptre is a glass whose focal 
length is one metre). If the distance of the near point is known in centi¬ 
metres, the equivalent in dioptres is found by dividing 100 by the near point 
in centimetres. Thus, if the near point be 20 centimetres, the amplitude 

of accommodation = 5 D. (A=P — R; or — - R , which 

' 20 cms. 

in this example is 0; hence A = 5 D.) The near point (P) can be found 


t s 



Fig. 66.—Diagram showing the corneal axis, U-E; the optic axis, 

O-A; the visual line, R-Y; the line of fixation, 

R-J ; and the three angles. 

The angle between U-E and the visual line, R-Y, is the angle alpha, averaging five de¬ 
grees. The angle between the optic axis, O-A, and the line of regard, R-J, is the angle 
gamma. The angle between the optic axis, O-A, and the line of vision, R-Y, is the angle 
beta. TS = temporal side ; NA = nasal side. 


by ascertaining the nearest distance at which the patient can read fine 
print; the distance is then measured by a steel tape marked both in dioptres 
and in centimetres. 

Optical Defects. —The eye is not a perfect instrument, since it is not 
exactly centred, and possesses chromatic and spheric aberration in a small 
degree. In a perfect optical instrument the lenses are exactly centred, 
and the visual line corresponds to the axis of the lens-system. The optic 
axis of the human eye passes through the centre of the cornea, but not 
through the centre of the lens, and does not touch the fovea centralis: the 
region of distinct vision. The line of vision is the line connecting the 
object viewed, the nodal point, and the fovea. The line of fixation con¬ 
nects the object with the centre of rotation , which is placed 6 millimetres 
behind the nodal point. The angle included between the major axis of 







PHYSIOLOGY OF VISION. 


69 


the corneal ellipse and the visual line is called the angle alpha , and meas¬ 
ures about five degrees. The angle included between the optic axis and 
the line of fixation is named the angle gamma. The angle between the 
optic axis and the visual line is named the angle beta. These are shown 
in Fig. 66, and will be referred to in the chapter on refraction. 

In the normal (emmetropic) eye the principal posterior focus lies 
on the retina. The myopic eye has its principal posterior focus in front 
of, and the hypermetropic eye behind, the retina. These must be consid- 



Fig. 67.—Diagram to show spheric aberration. 
The distance from S to R is the focal line of Sturm. 


ered as abnormal eyes, although, since at birth and in infancy all eyes are 
hypermetropic, some writers contend for the adoption of the hypermetropic 
eye as normal. In the middle and later periods of life presbyopia (old 
sight) appears, owing to a diminution in the elasticity of the lens or a 
weakness of the ciliary muscle. All these conditions can properly be con¬ 
sidered pathologic, and will be discussed in the chapter on refraction. The 
normal eye, however, is subject to certain defects: spheric and chromatic 
aberration and astigmatism. 


L P T 



Fig. 68.—Diagram to show chromatic aberration. 

O o 


Spheric Aberration. —Bays of light which traverse the peripheral 
parts of the lens are brought to a focus sooner than those which pass 
nearer the centre. This inequality is known as spheric aberration. The 
interval between the foci is known as the focal line of Sturm (Fig. 67). 
The iris, acting as a diaphragm, shuts off the peripheral rays and corrects 
this defect. 

Chromatic Aberration. —Different rays of the spectrum are bent 
to different degrees. Violet rays, being more refrangible than red, will 


















TO 


MODERN OPHTHALMOLOGY. 


have their focus nearer to the lens. This inequality is known as chromatic 
aberration. In the manufacture of optical instruments the defect is over¬ 
come by combining a convex with a plano-concave lens, each made of a 
glass with different refractive index. In the human eye practically the 
same arrangement of lenses exists, and, owing to ability rapidly to change 
accommodation, chromatic aberration attracts little notice. That chromatic 
aberration exists in the eye can be demonstrated by the study of Fig. 68. 
The chromatic test for errors of refraction is based on chromatic aberration. 

In Fig. 68 let it be supposed that G is a luminous point, E-S the 
dioptric surface, and P to be the plane of the mean focus of G. Violet 
rays, E-M and S-B, will be brought to a focus in the plane L; the red 
rays, E-A and S-F , in the plane T. If the rays fall on the retina between 
L and P, the diverging, or blue, rays will form a centre around which will 
be the converging red rays, E-A and S-F. If the rays fall on the retina 
between P and T, the converging red rays will form a centre bordered by 
the diverging blue rays, E-M and S-B, around them, provided those lines 
were carried to the plane, T. 

Astigmatism. —The dioptric surfaces of the eye are not parts of 
perfect spheres. Slight variations do not cause inconvenience, but marked 
differences in the curvature of the refracting surface in different meridians 
will reduce vision. Most eyes possess a small amount of regular corneal 
astigmatism (regular because the meridians of greatest and least refrac¬ 
tion are at right angles), the cornea being of greater convexity in the 
vertical meridian. Occasionally regular astigmatism is due to the unequal 
curvature of the lens. Irregular astigmatism, the principal meridians being 
placed otherwise than at right angles, exists in the normal lens to a slight 
extent. It is this which causes a star to look, not round, but pointed. 

Lack of Transparency. —The dioptric media of the eye are not 
perfectly transparent, as is shown by the presence of small, bead-like bodies 
(musca volitantes) which are seen when one looks through a microscope. 
They are due to floating particles in the vitreous humor. 

Functions of the Iris.—The iris is a diaphragm cutting off light which 
otherwise would pass through the periphery of the lens and thus cause 
spheric aberration. It also forms a support for the ciliary muscle in accom¬ 
modation. 

With the eye at rest the pupil enlarges; in accommodation it becomes 
smaller. The movements of the iris are under the control of a delicate 
nervous arrangement as follows: The ciliary nerves (branches of the 
lenticular ganglion) pierce the sclera near the entrance of the optic nerve, 
pass forward between the lamina fusca and the chorioid, and supply the 
ciliary muscle, iris, and cornea. They distribute sensory filaments from 
the fifth nerve to the eyeball; motor fibres to the ciliary muscle and to the 
sphincter of the iris from the third nerve; and sympathetic fibres from 
the cavernous plexus, which on irritation cause the pupil to dilate. 

The pupil is constantly changing in size, so that no physiologic stand- 


PHYSIOLOGY OF VISION. 


71 


ard of measurement can be adopted, although it is generally stated that 
the average diameter is 4.4 millimetres. It is large in children and small 
in the aged. 

Contraction of the Pupil occurs normally (1) in response to 
stimulation of the retina by light, and (2) during accommodation. The 
abnormal conditions causing contraction are numerous, and embrace the 
poisonous effects of certain drugs and gases and the manifestations of 
certain nervous diseases, all of which will be considered in the clinical 
part of this treatise. 

Dilation of the Pupil is brought about normally (1) when stimu¬ 
lation of the retina is diminished or absent, as in passing from a brightly 
lighted to a dark room; and (2) when the eye is directed toward distant 
objects. Abnormally, contraction occurs in poisoning by some drugs, in 
certain nervous diseases, and in certain pathologic conditions of the eyeball. 

Constriction of the pupil is brought about by the action of the cir¬ 
cular muscular fibres found in the pupillary margin of the iris. Dilation 
is an action whose exact mechanism is still a subject of debate. Some 
physiologists hold that it is simply a negative act: that, when the sphincter 
pupillae relaxes, the elastic radiating fibres of the iris cause the enlarge¬ 
ment; while others claim the existence of special dilating fibres. 

Contraction of the pupil in response to the stimulus of light falling 
on the retina is a reflex act, the optic being the afferent nerve, the motor 
oculi the efferent path, and the centre being situated in the floor of the 
aqueduct of Sylvius. 

Aside from this optic-oculomotor reflex mechanism there are other 
agencies which influence the pupil. Thus, section of the cervical portion 
of the great sympathetic nerve is followed by contraction. If the upper 
end of the sympathetic is stimulated, the pupil becomes larger. This 
influence of the sympathetic upon the iris is the antipode to what occurs 
to the blood-vessels. When the sympathetic nerve has been sectioned, the 
vessels of the head and neck become enlarged, nasal and lacrimal secretion 
are increased, the temperature of the corresponding side of the head is 
raised, and the pupil contracts. When the sympathetic has been stimulated 
the vessels contract, but the iris dilates. Excision of the superior cervical 
ganglion of the sympathetic shows that in the human subject the removal 
of this part of the sympathetic nerve is followed by dilation of the vessels 
and contraction of the pupil. 

In the lower animals a set of pupil-dilating nerve-fibres can be traced 
from a centre located in the floor of the front part of the Sylvian aqueduct. 
Thence it passes through the cervical part of the spinal cord, the anterior 
roots of the upper dorsal nerves, the upper thoracic ganglion, and the cer¬ 
vical portion of the sympathetic nerve. It can be further traced through 
a branch of the superior cervical ganglion, which passes upward with the 
internal carotid artery, and thence over the Gasserian ganglion to the 
ophthalmic division of the fifth nerve. From this point the nerve-fibres 


MODERN OPHTHALMOLOGY. 


pass through the nasal branch and the long ciliary nerves to supply the 
eye. These fibres are constantly active. If sectioned in any part of their 
course, contraction of the pupil follows; stimulation of the distal end of 
the divided nerve causes dilation of the pupil. The short ciliary nerves 
must be regarded as carrying pupil-constricting impulses, while the pupil- 
dilating impulses traverse the long ciliary nerves. 

The optic-oculomotor mechanism adapts the pupil to the amount of 
light, and the sympathetic mechanism transmits emotional and sensory 
influences. Dilation of the pupil occurring during fear or during pain 
is due to the sympathetic. 

Certain drugs act on the iris independently of nervous connection. 
An eye in which the optic, oculomotor, and sympathetic nerves have been 
cut will still dilate to atropin or contract to eserin. Such drugs act in a 
local manner on the sphincter of the pupil. 

The fifth is the sensory nerve of the iris. It also carries the dilating 
fibres of the sympathetic. 

Associated Action between the accommodation and convergence is 
interesting. Whenever we look at a near object the eyeballs converge and 
the pupils become small. When the eye is turned to a distant object the 
pupil dilates. These are examples of “associated movements.” 

Monocular Diplopia.—Schemer’s experiment, which was used by its 
author to prove accommodation, shows that double vision can be had with 
one eye alone. The experiment is as follows: Take a piece of cardboard, 
and with a pin make several holes so close to one another that two or more 
will occupy a space of less diameter than the pupil. Now place the card 
in front of one eye, closing the other, and look at a pin placed at the read¬ 
ing distance. It will be seen properly, only somewhat dimmed; if brought 
nearer or (in myopia) placed farther from the eye, it will be seen double. 
Under some pathologic conditions monocular diplopia occurs. 


OCULAR MOVEMENTS AND BINOCULAR VISION. 

Movements of the Eye. —The movements of the eye are limited prac¬ 
tically to its rotations around a centre which Donders and Dojer found 
to be 10 millimetres in front of the posterior surface of the sclera, or 14 
millimetres behind the summit of the cornea. This is the centre of rota¬ 
tion. The six muscles attached to each eyeball cause the globe to rotate 
around three axes, which pass through the centre of rotation. The axis 
of the external and internal recti is vertical, while the axes of the other 
pairs of muscles (superior and inferior recti, superior and inferior obliques) 
are in the horizontal plane. 

In order to avoid confusion it is perhaps well to define the three 
planes of separation of the eyeball: (1) the horizontal plane of separation 
divides the globe into an upper and a lower half, (2) the vertical plane 
divides it into an outer and an inner half, and (3) the equatorial plane 


PHYSIOLOGY OF VISION. 


73 


divides it into an anterior and a posterior half. The horizontal and ver¬ 
tical lines of separation of the retina intersect in the fovea centralis, and 
divide the retina into four quadrants. It is necessary to call attention to 
the positions of the eyeball , which are four in number: (1) the anatomic 
position of rest; (2) the functional position of rest, or primary position; 
(3) the secondary positions, due to movements from the primary position; 
and (4) the tertiary positions. 

The anatomic position of rest obtains in the eyes of the dead and in 
sleep. It is due to the form of the orbit, the length and insertion of the optic 
nerve, and the length of the muscles when not innervated. It is usually 
widely divergent, rarely parallel, and almost never convergent. Since the 
functions of the eyes cannot be performed in this position (because devia¬ 
tion would cause diplopia), it follows that, on awakening, the eyes uncon¬ 
sciously assume parallelism, and thus are in the functional position of 
rest. In this position the eyes may be said to be held taut by a delicately 
balanced muscular harness. The lines of vision are parallel and the visual 
planes are horizontal. This position is called “functional,” because the use 
of the eyes produces it, and it is called the “position of rest,” for the reason 
that normal eyes naturally assume this position without conscious innerva¬ 
tion or strain. The secondary positions result when movements from the 
functional position of rest occur. Secondary positions are of two kinds: 
(a) the visual lines are parallel, but are directed upward or downward; 
and (b) the lines of vision converge or diverge. The amount of deviation 
is expressed by the angle of lateral rotation. From the primary position 
(functional position of rest) the eye can be rotated 42 degrees outward, 
45 degrees inward, 34 degrees upward, and 57 degrees downward. The 
tertiary positions are caused by movements of the eye in which the lines 
of vision are convergent and at the same time are directed upward or 
downward. 

The movements of the eyes in their various directions are accomplished 
by the extra-ocular muscles in accordance with Listing’s law, viz.: when 
moved from the functional position of rest, the angle of rotation in the 
second position is the same as if the eye were turned about a fixed axis 
perpendicular to the first and second positions of the line of vision. Phys¬ 
iologists have shown that in moving from the primary position into any 
other there is practically no wheel movement of the eyeball around the 
visual axis, although Javal has demonstrated a slight rotation in this 
direction. This fact was verified by Helmholtz. The movements of the 
eyes are direct and oblique, and are the result of the action of muscles as 
follows:— 


Direct 

movements 


' Nasally.Internal rectus. 

Temporally.External rectus. 

Upward.Superior rectus and inferior oblique. 

Downward.Inferior rectus and superior oblique. 







74 


MODERN OPHTHALMOLOGY. 


Oblique 

movements 


Upward and nasally.Superior and internal recti and in¬ 

ferior oblique. 

Downward and nasally.Inferior and internal recti and su¬ 

perior oblique. 

Upward and temporally.Superior and external recti and in¬ 

ferior oblique. 

Downward and temporally... Inferior and external recti and su¬ 
perior oblique. 


Protrusion and Retraction Movements.— The eyes protrude when the 
return of venous blood is interfered with, as in hanging; in contraction 
of the unstriped muscular fibres of Tenon’s capsule, innervated by the cer¬ 
vical sympathetic; in forced opening of the lids, which diminishes pressure 
on the globe; and in excessive action of the oblique muscles. The eyes 
retract when the lids are closed forcibly, in atrophy of the orbital tissues, 
and after excision of the superior cervical ganglion of the sympathetic 


t 


2 


3 



Fig 69.—Diagram to show (1) the primary position of the right eye; 

(2) the eye turned upward and inward, and (3) 
downward and outward. 

er, External rectus, ir, Internal rectus, so, io, Superior and inferior obliques. 
sr, ifr, Superior and inferior recti. 

nerve. It will be observed that the conditions under which the eyeball 
moves antero-posteriorly are usually pathologic. 

Relative Ocular Movements.—Normally the eyes move in unison be¬ 
cause of the necessity of having an image fixed on each fovea. If we look 
at an object at a certain distance, and then at another at the same distance, 
the eyes make associated movements, both turning up or down, to the 
right or to the left, as required, one eye moving as much as the other. 
When the objects are both situated in the same median plane, in order to 
fix from the distant to the nearer one, a movement of convergence is re¬ 
quired, both eyes turning inward to the same degree. When two objects 
are in different directions, the second nearer than the first, a combination 
of associated and convergent movements is necessary. A movement of 
one eye causes the other to move also, or at least to attempt to move. The 
impulse to binocular single vision disappears during sleep, when the eyes 
assume the anatomic position of rest. When struggling against sleep, or 
when suddenly awakened, a momentary diplopia is noticed. 











PHYSIOLOGY OF VISION. 


75 


Blindness During Ocular Movements. —Dodge has shown that in the 
fractional part of a second in which the eyes move the individual is prac¬ 
tically blind. The proof of this is that one is never able to see the move¬ 
ment of his own eyes in a mirror. 

Binocular Single Vision. —Binocular vision means the union in one 
single impression of images received simultaneously on both retinae. Under 
normal conditions an image of every object looked at is impressed on each 
retina. The question arises: how is it that these images are blended so 
that the observer is conscious of but one object? Two chief theories have 
been proposed for the solution of the problem: (1) the theory of identical 
points, and (2) the theory of projection. The latter theory assumes that 
the retino-cerebral apparatus, by a process of mental projection of the 
image into space, has the power of appreciating the shape and size of an 
image, as well as the direction of the rays of light which form it. While 
the limits of this treatise will not permit an extended discussion of the 
subject of binocular single vision, it will be necessary to consider the first 
theory more extensively. 

The theory of identical points assumes a correspondence of each point 
of one retina to a similarly situated point on the retina of the other eye. 
When the eyes are directed toward a far-distant object, the visual axes 
being then parallel, a correspondence actually exists; but when the visual 
axes converge the points do not converge. Furthermore, a part of each 
retina has no corresponding points in the other. This is due to the fact 
that the actual centre of the retina is not at the fovea centralis, but lies 
nearer the nasal side. So long as the images of a point are within the 
horopteric circle they fall on corresponding parts of the retina?. Images 
of a point outside this circle do not fall on corresponding points. 

This circle, the horopter of Joannes Muller, may be described as being, 
in the simplest form, a circle which embraces the centre of rotation of 
each eye and the apex of the point of fixation of the visual lines. Thus, 
in Fig. 70 it is a simple problem in geometry to demonstrate that images 
of any point lying within the horopteric circle fall on corresponding 
retinal points. Thus, the images of B will fall on such points. For, if C 
and D are nodal points of the two eyes, and F and H are the centres of 
the foveae, the angles D-A-C and D-B-C —being angles in the same seg¬ 
ment of a circle—are equal. In the triangles A-I-C and B-I-D , the angles 
A-I-C and B-I-D —being opposite angles—are also equal. Therefore, the 
angles A-I-C and B-I-D are equal; and the angles E-C-F and G-D-II are 
equal. Now, if the left eye be placed on the right, so that C-F corresponds 
with D-H, G must correspond with E. 

Since the doctrine of identical points is true for only some visual 
acts, an attempt must be made to explain binocular single vision without 
the horopter. Such objects as are situated outside the horopter are seen 
double, but it is possible to obtain only a single cerebral impression of 
them. Thus, the expert ophthalmoscopist keeps both eyes open while 


76 


MODERN OPHTHALMOLOGY. 


examining the fundus. The image seen by one eye in this case is ignored. 
Under some circumstances a new mental picture of two combined dis¬ 
similar retinal impressions is made. Thus, ideas of solidity and depth 
are obtained in binocular vision by the mental combination of dissimilar 
retinal impressions, as in using the stereoscope. This is an instrument 
by means of which two somewhat similar pictures, drawn in perspective, 
are superimposed so that they appear single. One reason why non-identical 
points yield good vision is that vision becomes less distinct as we pass from 
the centre of the retina, and the observer learns to neglect the blurred 
peripheric images while giving attention to those formed on the fovea. 


A 



Stereoscopic Vision. —This is another name for binocular vision, or 
the sense of depth. The law of identical points was supposed to be abso¬ 
lute up to the time that Wheatstone constructed his stereoscope. This 
shows that the perception of depth is caused by a slight non-identity of 
the two retinal images. An object appears to us to be solid when each 
eve views it from a different point, as in normal vision. Thus, let the 
observer look at a house. One eye sees more of one side of the house than 
the other, and vice versa. Thus, each eye has its own picture of the house, 
and the simultaneous use of both eyes gives us a correct idea of the third 
dimension. It is the unlikeness of the two pictures which gives the idea 
of depth. The stereoscope is an instrument for viewing two similar pic- 







PHYSIOLOGY OF VISION. 


77 


tures which are made to overlap, giving the appearance of solidity and 
depth. The stereoscopic field of vision, or region in which the visual fields 
of the two eyes overlap, subtends an angle of about 90 degrees. 

Binocular vision is acquired during the first months of life. In babes 
the eyes wander aimlessly; soon, however, the child learns to fix objects, 
and this marks an important event in its ocular and cerebral development. 

FUNCTIONS OF THE RETINA. 

The part of the retina essential to vision is the layer of rods and cones. 
It cannot be said, however, that the retina sees: what it does is to receive 
stimuli of light. These are transmitted via the optic nerves and tracts to 
the brain, where certain changes occur, the nature and site of which are 



Fig. 71.—Diagram of the field of binocular vision. 

The field for the left eye is bounded by the black line ; that for the right eye is hounded 
by the interrupted line. 1, 2, Physiologic scotomata. S, Fixation-point. 


entirely unknown. The resulting sensation of light is elaborated into 
perception of external objects and judgment of the relation which these 
objects bear to each other and to the observer. Stereoscopic vision having 
been mentioned already, it will be necessary to consider now the field of 
vision, the blind spot in the field, the region of most distinct vision, the 
duration of visual sensations, the inversion of the image, color-vision, and 
other topics naturally included under the head of the functions of the 
retina. 

The Field of Vision. —Every eye possesses a certain amount of indirect, 
or peripheral, vision, which when outlined upon a surface is called the field 
of vision. The recording of this peripheral power of the retina is called 
measuring the field of vision. The methods used in its determination are 
discussed in the succeeding chapter. It is sufficient in this place to state 



78 


MODERN OPHTHALMOLOGY. 


that the field varies according to the facial configuration of the individual 
and the test-color used, being more extensive on the temporal side than 
on the nasal, superior or inferior; and more extensive for white than for 
colors. The position of the eye in the orbit, the prominence of the bones 
at the base of the orbit, the length of the optical axis, and the size of the 
pupil are all factors influencing the form of the visual field. The dimen¬ 
sions of the normal field for white and colors are:— 


Temporally 
Nasally .. 
Superiorly 
Inferiorly 


White. 

Blue. 

Red. 

Green 

o 

o 

0 

0 

O 

<X) 

65° 

50° 

60° 

55° 

50° 

0 

O 

45° 

4^ 

O 

0 

0 

‘O 

CO 

30° 

70° 

0 

O 

O 

45° 

35° 



Blue_ 

Yellow _ 240' 

Red_ 

Green_ 


255 


90' 


500' 


270 • 


2S3' 


Fig. 72.—Diagram of the normal visual field for white and 

o o 

colors. (Jexnings.) 

The outer, continuous line indicates the limit of the field for white, and the broken lines 
indicate the limits of the color-fields. 


The Blind Spot.—At the point where the optic nerve enters the globe 
there are no retinal elements; hence this part of the visual field is blind. 
A demonstration of the blind spot can be made by a simple experiment. 
Let the observer close the left eye and with the right look intently at the 
cross in Fig. 73, the book being held at about twelve inches’ distance. At 
or near this point the black circle will disappear. At that instant rays of 































PHYSIOLOGY OF VISION. 


79 


light from the circle strike the head of the optic nerve and the black spot 
becomes imperceptible. The form of the blind spot as determined by 
perimetry is elliptical. Its existence proves that the fibres of the optic 
nerve are insensible to light, which can stimulate them only by means of 
the retina. 

The Macula Lutea.—This is the region of most distinct vision, and 
it is here that the end-organs of the optic nerve are most highly developed. 
In daily use of our eyes we unconsciously look directly at objects. Then 
the image is received on the maculse and perception reaches its maximum 
acuity. Any pathologic change in the macular region diminishes visual 
• acuity to a marked extent. Rays of light reaching any other part of the 
retina result in the formation of an indistinct image. 

Direct and Indirect Vision.—We speak of direct vision when the 
image falls on the centre of the macula. Indirect vision occurs when the 
rays from an object fall on the peripheral part of the retina. Indirect 
vision—although much less acute than direct—is of great assistance in 
diminishing movements, changes, or intermission of visual impressions 
(Exner). Direct vision is tested by means of types; and indirect vision 
is tested by the use of the perimeter. 




Fig. 73.—Diagram to show the blind spot in the visual field. 


The Rods and Cones in Vision.—The statement has been made that 
the part of the retina essential to vision is the layer of rods and cones. 
That this is true is shown by the figures of Purkinje. It was this physi¬ 
ologist who first showed that the shadows of the blood-vessels of the retina 
can be seen under favorable conditions, although they are ignored in ordi¬ 
nary vision. If, by oblique illumination, light is concentrated far back 
upon the sclerotic, the eye being directed to a dark background, images 
of the retinal vessels will be seen as shadows. Since the vessels lie in the 
anterior portion of the retina, it must follow that in Purkinje’s experi¬ 
ment their images are perceived by some part of the retina behind the 
vascular layer. It has been shown by mathematical calculations, based 
on the movement of shadows following the movements 6i the illumination 
in the experiment mentioned, that the visual impulses originate in the 
outermost part of the retina: i.e., in the layer of rods and cones. Another 
argument in favor of the rods and cones as the sensitive part of the retina 
is furnished by these facts: Since the sensitive part is shown by Purkinje’s 
experiment to be behind the vascular layer, it must be admitted that the 
part of the retina essential to vision is either the layer of rods and cones, 
the external nuclear layer, or the pigmented epithelium. The layer of 


80 


MODERN OPHTHALMOLOGY. 


pigment-cells is excluded, because albinos, both human beings and animals, 
in whom this layer is absent, possess vision. The external nuclear layer 
can be excluded for the reason that it is practically absent in the part of 
the retina where vision is most acute. 

Consideration of the nature of the change in the layer of rods and 
cones which is necessary to the transmission of stimuli is pure speculation. 
Nevertheless the statements to follow may be assumed to represent cor¬ 
rectly the present state of our knoivledge of visual sensation. The stimulus 
which excites vision consists of ether-waves, which are disturbances of 
definite periodicity in space and time. Variations in the length of waves 
produce different effects on the retina, and are of importance in exciting 
a definite series of color-sensations. Physicists tell us that there is no real 
distinction between heat- and light- waves. The length of wave which 
excites extreme red is thirty-two millionths of an inch. 

The effects produced on sentient cells by light are: (1) a change in 
color of the purple of the rods, ending in complete bleaching; (2) retrac¬ 
tion of the cone, which previously projected into the pigment epithelium; 
and (3) the generation of an electric current, which travels from the pig¬ 
ment epithelium to the nerve-fibre layer, and is positive. 

Many theories have been advanced in explanation of the retinal changes 
accompanying the visual act, and of these the most plausible is founded 
on the rediscovery of the visual purple by Boll. This, the photochemical 
theory, has not cleared the mystery. The limits of this work preclude a 
discussion of the subject. It is necessary, however, to mention the retinal 
pictures. 

Optograms, which are pictures appearing on the retina after exposure 
to light, are due to bleaching of the retinal red. They can be obtained 
by this process: Enucleate the eye of an animal in a dark-room, and keep 
the eye in a closely covered box. Then direct it toward a window and 
expose it to bright illumination for a few minutes. The eye is then taken 
into a dark-room and examined. A picture of the window will be found 
on the retina, the window-glass appearing light and the sash dark. 

Duration of Visual Sensations. —The duration of a visual sensation is 
always greater than that of the stimulus causing it. However brief the 
stimulus, the retinal effect lasts about one-eighth of a second. A common 
experiment in evidence of this proposition is to look at a wheel revolving 
rapidly. The spokes do not appear as separate radiating lines, but the 
wheel seems to be one solid mass. This is because each spoke follows 
another so rapidly that one impression cannot disappear before another is 
produced. When the stimulus is of some duration, the observer can distin¬ 
guish between that part of the sensation occurring while light still falls on 
the eye and that part which remains after the light has ceased to reach the 
retina. The latter portion is known as an after-image. Physiologists 
classify after-images as positive and negative. The former will generally 
be of the same color as the stimulus producing them, while the latter, which 


PHYSIOLOGY OF VISION. 


81 


are due to fatigue of the stimulated retina, as a rule assume a comple¬ 
mentary hue. Thus, if the observer looks for an instant at a very bright 
light, as at the sun, and closes the eyes, after-images of the luminous body 
will remain for a few seconds. 

Irradiation. —Luminous impressions often are not confined to the 
retinal elements directly involved, but extend to adjacent elements. This 
leads to deception as regards the dimensions of objects. Thus, in Fig. 74, 
the two circles are of the same diameter, yet the white circle on the black 
ground appears the larger. On prolonged inspection of the objects the 
deception increases. Irradiation is to be explained by the aberration of 
the dioptric media of the eye. Not all the rays coming from an object are 
focused on the retina, and thus the image is surrounded by diffusion circles 
separating it from the unilluminated area. 

Relation of Sensation to the Intensity of the Stimulus. —Physiologists, 
by comparing the visual sensations caused by different degrees of lumi¬ 
nosity, have found that, within certain limits, the smallest difference of 
light which the human eye can appreciate is about 1 / 100 of the total 
luminosity. 



Fig. 74.—Diagram to show irradiation. 

Time Necessary for Excitation of the Retina by Light. — This is 
exceedingly small. It has been computed that light thrown from a rotating 
mirror stimulates the eye when acting for only Vsoooooo P ai ’t a second. 

Clearness of Vision is dependent on the space between the retinal 
cones in the macula lutea. To be clearly seen an object must practically 
subtend an arc of 60 or 70 seconds in the field of vision. The image of such 
an object produces an image of about 1 / 12 000 of an inch in the retina, and 
this is approximately the distance between, the cones. 

Inversion of the Image. —It is known from the laws of optics, and 
from experiments, that the image formed upon the retina is inverted; yet 
it is perceived as an upright object. Why is it that objects are seen erect 
when their images are inverted? Without discussing the question exten¬ 
sively it is sufficient to say that it is the result of lifelong habit. A person 
born blind, and remaining in that condition for many years, as a result 
of a successful operation, has his sight given him, but is unable by this 
sense alone to tell the difference between a cube or a sphere, a dog or a 
cat. All objects appear to him as flat. Soon, however, aided by the sense 
of touch, he appreciates form, and guided by experience he soon learns to 
view the external world normally. By touch the individual corrects his 





82 


MODERN OPHTHALMOLOGY. 


mental impression, and soon the brain learns to make the correction inde¬ 
pendently. In discussing this question Helmholtz said that, since “our 
natural consciousness is completely ignorant, even of the existence of the 
retina and of the formation of images, how should it know anything of the 
position of images formed upon it?” 

The Visual Centre.—The visual fibres in man pass from the optic tract 
to the external geniculate body and pulvinar. Thence the visual impulse 
traverses fibres which pass through the posterior end of the internal capsule 
and run, as the optic radiations of Gratiolet, to the cerebral cortex in and 
around the calcarine fissure (Munk’s visual centre). It is not known 
whether the nerve-cells of this area are the seat of conscious impressions 
or are merely substations on the way to higher centres. Whether the same 
brain-cell is capable of appreciation of differences in color as well as in the 
amount of light-effect is also unknown. 

Color-perception.—When a beam of sunlight is passed through a prism 
it is decomposed into a series of colored rays called the solar spectrum. 
These spectral colors are red, orange, yellow, green, blue, indigo, and violet. 



Fig. 75.—Diagram of the decomposition of solar light into 
the spectral colors. (Jennings.) 

They are called simple colors because they cannot be further decomposed. 
The shape of the spectrum is elongated for the reason that the violet rays 
are more refrangible than the red ones. The spectral colors are said to 
consist objectively of rapid transverse vibrations of the all-pervading ether, 
from four hundred millions of millions per second for red to about seven 
hundred and sixty millions of millions for violet. Subjectively they are 
sensations caused by the impact of ether vibrations upon the retina. White 
light, having been decomposed into the colors named above, can be recom¬ 
posed by means of a biconvex lens. Another method of making white light 
from a combination of the spectral colors can be demonstrated by means of 
Newton’s disc, which is a piece of cardboard on which five spectral colors 
are pasted in the shape of triangles radiating from the centre, which is 
black. By rapidly rotating the disc the observer sees a grayish-white color. 
Since the duration of retinal impressions is greater than the stimulus 
causing them, a mixture of the colors occurs, with grayish white as a 
result. 

Colors are distinguished according to (1) their hue, (2) their purity, 
and (3) their brightness. Tone, or hue, depends on the wave-length: i.e ., 







PHYSIOLOGY OF VISION. 


83 


the position of the color in the spectrum. Purity, or saturation, depends 
on the white which is found in nearly all colors except those of the 
spectrum: the less the amount of white, the greater the purity of the 
color. The intensity, brightness, or shade depends on the intensity of the 
illumination. Complementary colors, those which when mixed produce 
white, are as follows:— 

Red and greenish blue. Yellow and indigo-blue. 

Orange and cyanogen-blue. Greenish yellow and violet. 

Red is complementary to green-blue, green to purple, yellow to indigo, and 
orange to blue. 

These are spectrum-colors, and their fusion gives a result different 
from that obtained by the mixing of pigments of the same colors. Thus, 
the yellow and. indigo-blue of the spectrum make white, while the same 
pigment-colors produce green. 

Black is a sensation which corresponds to a state of rest of the eye. 
There are no completely black objects in nature: those which seem blackest 
reflect a considerable quantity of light. 

Normal Variation in Color-perception. —While it has long been known 
that certain individuals cannot distinguish between red and green, it has 
been supposed until recently that with the exception of these color-blind 
persons the rest of the human race could distinguish colors accurately. 
The recent experiments of Eood show that there is as much variation in all 
people in the power of accurate color-perception as in visual acuity. His 
observations were carried out by means of the flicker photometer, for the 
purpose of comparing his own color-vision with that of others. lie found 
that not a single person agreed with him, and no two agreed with each 
other. In further study of the subject he compared his own with the 
color-perception of eleven persons. It was found that they could be divided 
into two classes according to their perception of green. The average color- 
vision of the eleven was taken as the normal standard, and the divergence 
of each person from this standard was then calculated. 

Theories of Color-perception. —These are numerous. No two of them 
agree and not one is entirely satisfactory. The whole question resolves itself 
into the fact that there is a pair of receptive elements with adaptive ap¬ 
paratuses that are capable of receiving light-rays and transferring them 
into energies that are carried to the occipital cortex, in which situation they 
are gotten ready for perception. 

The Ocular Adnexa. —The eyelids afford protection to the globe. The 
eye is opened by the action of the levator of the upper lid (which is 
innervated by the third nerve) assisted by depression of the lower eyelid. 
The eye is closed by contraction of the orbicularis palpebrarum muscle, 
which is supplied by the facial nerve. Closure is generally a reflex act, 
but is under voluntary control. The reflex act of winking is under the 
control of afferent impulses' carried by the ophthalmic division of the fifth 


84 


MODERN OPHTHALMOLOGY. 


nerve and efferent impulses transmitted by tlie facial. Since the levator 
palpebrse superioris muscle sends a slip to the superior rectus, contraction 
of the latter not only raises the visual axis, but also elevates the upper 
eyelid to a slight extent. The inferior rectus likewise depresses the visual 
axis and lower eyelid. 

The conjunctiva is the membranous covering of the eyelids and globe. 
It is constantly kept moist by the secretion of the lacrimal gland of the 
orbit and the accessory glands found in the lids. The fluids thus formed 
ordinarily disappear partly by evaporation, partly by way of the drainage- 
apparatus. The lacrimal fluid is slightly alkaline in reaction, containing 
about 1 per cent, of solids, among which sodium clilorid is noticeable. 
Excessive lacrimal secretion, or the production of tears, is a reflex act 
occurring in response to irritation applied to the conjunctiva, cornea, skin 
of the face, nasal mucous membrane, tongue, buccal mucous membrane, 
or any peripheral irritation or lesion causing pain. It also occurs in 
response to the emotions and as a result of stimulation of the retina by 
strong light. Section of the cervical part of the sympathetic nerve produces 
lacrimation. The sensory part of the fifth is the afferent nerve. The 
efferent fibres are found in the lacrimal and orbital branches of the same 
nerve. 

The flow of the lacrimal secretion into the canaliculi, sac, and lacrimo- 
nasal duct occurs in response to mechanical force, in which the chief factors 
are capillarity, gravity, and the movements of the lids. The act of winking 
rapidly prevents an overflow of tears. Henke has compared this action 
to that of a suction-pressure pump. The generally accepted view is that 
muscular action expands the lacrimal sac, into which the tears are drawn. 
The sac is emptied by the passive contraction of its elastic fibres. 

Lacrimal secretion is generally absent from the eyes of the newborn, 
and is not noticed until about the second month of extra-uterine existence. 
The naso-lacrimal duct, often imperfect at birth, becomes patent about 
the same time. 


CHAPTER IV. 

EXAMINATION OF THE EYE. 


Examination of tlie eye includes ordinary inspection, inspection by 
the aid of lenses and instruments of precision, ophthalmoscopy, and func¬ 
tional testing. Inspection and ophthalmoscopy are fortunately independent 
of the answers of the patient; the functional tests depend entirely on his 
replies. All of the methods are of value. In addition to their use the sur¬ 
geon should secure a complete history of the case and should make a record 
of the same. Observance of this rule will not only save much time if the 
patient should return at a later period, but will furnish data of value to 
the profession. Furthermore, the possession of a case-history may protect 
the surgeon from a suit for alleged malpractice. A systematic plan of 
examination should be followed, the record being placed in book or card 
form. For this purpose the following order may be used:— 

Name. Residence. Age. Occupation. 

Sex. Color. Married, single, or widowed. 

General and ocular diseases of parents. 

Personal history of patient: constitutional diseases, acquired or hereditary; in¬ 
juries . 

Personal habits of patient: alcohol, tobacco, drugs, sexual relations. 


Date and symptoms of present trouble: pain in or around the eyes, symptoms 
caused by use of the eyes, etc. 

External examination: inspection of both eyes shows. 

Inspection of right eye: lids, conjunctiva, cornea, tension, pupil, etc. 

Inspection of left eye: lids, conjunctiva, cornea, tension, pupil, etc. 

Vision of right eye =.; improved by convex or concave sphere or cylinder 

Vision of left eye = .; improved by convex or concave sphere or cylinder 

Examination of right eye with ophthalmometer shows. 

Examination of left eye with ophthalmometer shows. 

(85) 
























86 


MODERN OPHTHALMOLOGY. 


Muscle-balance measured by Maddox rod, pliorometer, etc., shows 


Right 
Left. . 


Ophthalmoscopic examination shows 


Right 
Left. . 


Record of the visual fields 


Examination of color-sense 


Right 
Left.. 
Right 
Left.. 


Examination of refraction after the 
use of a mydriatic for.days 


Right 

Left. 


( Right... 

Examination by retinoscopv 1 

( Left. 

X-ray examination by Dr. 

Diagnosis and prognosis. 

Local remedies ordered applied. 

Internal remedies prescribed. 

f Right 

Glasses and frames prescribed -! 

( Left. 

Patient is to return... 

Patient referred by Dr. 

Remarks . 


Homatropin. 

Scopolamin. 

Atropin. 


EXTERNAL EXAMINATION. 

Having obtained the history of the case, attention is naturally first 
directed to the two eyes to determine any difference in appearance or lack 
of symmetry. Such marked difference as the absence of one eye, a turning 
of the globe, the presence of a swelling of an inflammatory nature, or the 
existence of a tumor or ulcer will immediately be noticed. In many cases, 
however, the departure from the normal is evidenced by slight changes, 
which call for minute examination. First in order will be inspection of 
the eyelashes. Notice should be taken whether the lashes are present in 
normal number, evenly distributed along the margin of the lid, or if 
certain spots seem to show too few cilia. Also it should be noted if the 
cilia are properly directed. If they turn toward the globe, note whether 
they are improperly directed (trichiasis) or if they are present in two or 
more rows of misplaced cilia (distichiasis). The lashes may be normally 
























EXAMINATION OF THE EYE. 


87 


distributed and directed; their ends do not taper to a fine point, but appear 
as stubs. In this case, ask if the patient has trimmed the lashes or has 
had them singed either intentionally or by accident. Search should be 
made for small, white, downy hairs, which may grow from any part of 
the lid-margin and are often found at the inner canthus, where they rub 
the globe or caruncle with every wink. Short, thick, black hairs, known 
by the laity as “wild hairs,” often cause much irritation. About the roots 
of the cilia parasites (phthiriasis oculorum) may be found. The matting 
together of the lashes with a moist substance will at once suggest the 
presence of some form of conjunctivitis. 

Eyelids. —Any change in color, size, contour, or motility of the lids 
should be observed. The lid is subject to eczema, xanthelasma, and other 
cutaneous diseases. A localized inflammatory swelling of the lid will 
suggest trauma, hordeolum, erysipelas, erythema, sarcoma, an inflamed 
chalazion, or acute circumscribed edema. A local non-inflammatory swell¬ 
ing may be due to a dislocated lacrimal gland or to a chalazion. In the 
latter case a hard, round body like a shot will be felt. A local non¬ 
inflammatory swelling may be due to nephritis. A general inflammatory 
swelling of the lid is met with in trauma, gonorrheal conjunctivitis, and 
erysipelas. A general non-inflammatory swelling may be caused by em¬ 
physema, in which case palpation will elicit the characteristic crepitation; 
or it may come from the accidental discharge of a solution which has been 
thrown into the cellular tissue while injecting the naso-lacrimal duct. 

An ulcer of the lid may be due to syphilis (chancre), in which case 
the pre-auricular gland will be enlarged, or to a malignant growth (epithe¬ 
lioma) . 

Nevi and varicose veins are sometimes seen in the lids. 

As regards motility, it is noticed in ptosis that the lid can be raised 
only by calling the occipito-frontalis muscle into action. 

In exophthalmic goitre the upper lid follows the globe slowly when 
the patient is told to look down (von Graefe’s sign) or is retracted (Dal- 
rymple’s sign) ; or the act of winking may be done at long intervals 
(Stellwag’s sign). Drooping of the lid, aside from inflammatory thick¬ 
ening, is found in paralysis of the cervical portion of the sympathetic 
nerve, which supplies the fibres of Muller’s muscle. Vertical narrowing of 
the palpebral fissure exists in enophthalmos. Imperfect closure of the lids 
is found in paralysis of the seventh nerve. The levator palpebree superioris 
muscle may act only in conjunction with another muscle or group of mus¬ 
cles. In these instances the patient always shows slight congenital ptosis. 
He should be told to look downward, opening his mouth widely and moving 
the jaw from side to side. It will be found that the levator then draws 
the lid well above the cornea. In some cases the levators act only in con¬ 
junction with the internal recti, convergence causing the upper lids to be 
retracted. 

The contour of the lid may be changed by scars from wounds, ulcera- 


88 


MODERN OPHTHALMOLOGY. 


tion, or burns. The finger should be passed along the lower part of the 
anterior surface of the upper and corresponding portion of the lower lid, 
to feel for thickened areas. If present, they will suggest tarsitis or occlu¬ 
sion of the Meibomian ducts. The position of the edges of the lids may 
be changed. A turning inward, entropion, will cause the cilia to brush 
against the cornea. A turning outward, ectropion, will expose the in¬ 
flamed and thickened conjunctiva and cause a flow of tears on to the 
cheek. Attention should be given to the shape of the lid-margin. Nor¬ 
mally the margin is rounded on the skin side, while the side toward the 
globe forms a right angle. In trachoma the posterior lip is worn away. 
Having inspected the external surfaces and margins, the examiner should 
proceed to the next step. 

Eversion of the Lids may appear to be a simple matter, but under 
pathologic conditions eyes may be injured by unskillful manipulation. 
Slight force expended in the proper way will enable the examiner to evert 
the eyelid without pressing on the globe. The procedure differs according 
to the age of the patient. In examining an adult the surgeon should stand 



Fig. 76.—Eversion of the upper eyelid. 

behind a chair on which the patient sits. The patient should look down¬ 
ward. The examiner, grasping the eyelashes of the upper lid between the 
thumb and index finger of the left hand, applies the index finger of. the 
right hand to the outer surface of the lid at a point midway between the 
lid-margin and the margin of the orbit. The lid is to be gently lifted 
over the fulcrum thus made by the right index finger. So long as 
the patient looks downward the turning of the lid is generally easily 
accomplished. 

To evert the lower lid of the adult the examiner should be seated 
facing the patient, who is to look upward. At the same time the examiner 
pulls the lid downward, the eversion being done by means of the thumb 
applied to the cutaneous side of the lid. 

In eversion of the lids of a child the surgeon is to sit facing the nurse, 
who, grasping the child’s hands and legs, places the patient in a horizontal 
position, the head being toward the examiner. Seizing the child’s head 
firmly between his knees, the surgeon is free to use both hands. Since 


EXAMINATION OF THE EYE. 


89 


children frequently are terrified and struggle, care must be taken to avoid 
pressure on the globe. Often, by waiting until the child becomes tired, 
the upper lid can be everted by simply making traction with the thumb 
placed at the orbital margin; or the lid may be everted over a match, 
which is used as a fulcrum. The eversion of the lower lid in the child is 
easily accomplished. 

The lids being everted,—first the upper, next the lower,—search should 
be made for pathologic conditions, such as conjunctivitis, fissures at the 
outer canthus, deformity of the upper tarsal plate, areas of ulceration, or 
patches of atrophied conjunctiva forming guy-ropes binding the lid to the 
globe. At the same time the condition of the cornea can be observed. 
Search for foreign bodies should not be omitted. By the methods described 
above the lower conjunctival fornix can be thoroughly explored, but not 
the upper. To explore this requires another procedure known as 

Secondary Eversion of the Upper Lid. —Having turned the upper 
lid and completed its inspection, the surgeon should retain the lid in its 



Fig. 77.—Examination of the eye of a child. 


everted position and pass beneath it, and into the upper fornix, a Noyes 
retractor (Fig. 78). This instrument is used to expose the entire upper 
fornix, which is a favorite location for trachoma and foreign bodies. Papil¬ 
lary tumors of the conjunctiva occasionally grow from this part, owing to 
the irritation caused by the lodgment of a foreign body. To render this 
procedure painless a few drops of holocain (1-per-cent, strength) can be 
dropped into the eye. Only rarely does it occur that spasmodic Closure 
of the lids cannot be overcome by the means just described. If so, a gen¬ 
eral anesthetic will be necessary. While the lids are everted any required 
application should be made. 

Ocular Conjunctiva. —At the same time that the palpebral con¬ 
junctiva is examined the condition of the ocular portion of this membrane 
should be determined. If undue redness is present, notice should be taken 










DO 


MODERN OPHTHALMOLOGY. 


whether it is greatest posteriorly, in the region of the fornices, or ante¬ 
riorly, around the corneoscleral junction. The presence of trachoma bodies 
or foreign substances will be noticed. Ulcerations of the oculai conjunctiva 
occur as broad, fiat losses of tissue, while in conjunctival tuberculosis the 
ulceration presents a thickened, irregular, mammillated appearance. Broad, 
hard patches of infiltration may be due to the initial lesion of syphilis or 
to a beginning epithelioma. Benign tumors occur in or immediately 
beneath the ocular conjunctiva. Localized patches of hyperemia, of a 
bright-red color, will suggest episcleritis. Invasion of the cornea by con- 



Fig. 78.—Noyes’s retractor. 


junctival vessels in the form of pannus is very common. A deep-pink zone 
of redness, involving vessels beneath the conjunctiva, suggests a deep-seated 
inflammation of the eye, involving particularly the uveal tract. To deter¬ 
mine whether the redness is in or beneath the conjunctiva the observer needs 
only to move the eyelid over the eyeball; and since the ocular conjunctiva 
is loosely attached to the globe, movement of this membrane can be readily 
caused. If the redness moves with the conjunctiva, it is due to conjunctival 
hyperemia; if not, it is deeply seated. Both forms of hyperemia may exist 
at the same time in the same eye. The deep-seated zone of redness is 
greatest immediately around the corneoscleral junction. 



Fig. 79.—Position for secondary eversion of the upper lid. 

. Nettleship distinguishes three systems in the blood-supply of the ante¬ 
rior part of the eye. These vessels, while scarcely to be seen in health, are 
prominent in disease. 

System I .—The posterior conjunctival arteries and veins ( A , Fig. 80). 
Hyperemia of these causes a bright-red color, which moves with the con¬ 
junctiva. It is associated with a muco-purulent discharge and indicates 
conjunctivitis. The greatest redness is in the fornices. 

System II .—The anterior ciliary vessels (B), which supply the sclera, 
iris, and ciliary body by means of perforating branches, while the non¬ 
perforating vessels supply the episcleral tissue. Congestion of these vessels 







EXAMINATION OF THE EYE. 


91 


produces a pinkish zone of circumcorneal congestion which does not move 
with the conjunctiva. Hyperemia of this system is present in iritis and 
cyclitis. Venous congestion of this region is often present in glaucoma 
as a dark, violet-colored zone. 

System III .—The anterior conjunctival and ciliary vessels. These 
are minute vessels which form loops in the peripheral part of the cornea. 
Hyperemia of these causes a bright-red discoloration around and partly in 
the cornea, and is typically seen in the early stages of interstitial keratitis. 

Lacrimal Apparatus. —The examiner should notice whether the 
puncta are directed properly, so as to take up the flow of tears. Often 
they are everted, or they may be directed properly and be closed; or eye- 



Fig. 80.—Diagram to show the vascular systems of the eye. 

A, Conjunctival vessels. B, Anterior ciliary vessels. C, Vena vorticosa. D, Posterior 
ciliary arteries. E, Central retinal vessels. 

lashes or other foreign bodies may be engaged in a canaliculus and pro¬ 
trude from the punctum. Normally the punctum cannot be seen except 
the lid be lifted away from the globe. 

The condition of the tear-sac can be determined by palpation. If 
pressure on it causes the discharge of mucus or pus into the nose below, 
or, as is more common, into the conjunctival sac above, the sac is diseased. 
If there is any doubt as to the patency of the drainage apparatus, a few 
drops of warm boric acid solution should be .injected from a hypodermic 
syringe armed with a blunt, hollow needle, which is placed in the lower 
canaliculus. If the fluid runs freely into the nose the canals are open. 
If the fluid returns into the conjunctiva via the upper canaliculus, there 
is either obstruction or stricture. While this statement is true of most 












92 


MODERN OPHTHALMOLOGY. 


cases, mention must be made of the fact that a growth of leptothrix occui- 
ring in the lower canaliculus has been known to permit the discharge of 
fluid from a syringe, while the mass caused epiphora, enlargement of the 
canaliculus, and practically lacrimal obstruction. 

Another method of determining the patency of the lacrimal passages 
is to place a few drops of a 2-per-cent, strength fluorescin solution in the 
conjunctiva. After waiting a minute or two the patient is told to use 
his handkerchief. The presence of the fluorescin stain will show that the 
passages are open. 

While in nervous subjects syringing of the naso-lacrimal apparatus 
should be preceded by the application of a local anesthetic to the con¬ 
junctiva, the author does not favor the injection of a cocain solution when 
the object is to determine the patency of the canal. The constricting effect 
of the cocain on the mucous membrane may lead to wrong deductions. 

The injection of a solution (1 to 10) of suprarenal extract into the 
lacrimal sac will often enable the surgeon to distinguish between simple 
inflammatory thickening of the drainage apparatus and true stricture. If 
the former condition exists, the apparatus soon becomes^ patent; if the 
latter, the epiphora continues (Bates). 

The accessory lacrimal gland may be seen by drawing the upper lid 
well away from the globe and at the same time having the patient look 
downward. The gland proper cannot be seen or felt under normal 
conditions. 

The Caruncle is sometimes deeper on one side than the other, owing 
to retraction following tenotomy of the internal rectus muscle. Neoplasms 
sometimes grow from it. 

The Sclerotic should be uniformly white in youths and adults and 
yellowish in very old people. In children it is of a bluish tint. If a bulg¬ 
ing of the sclera is seen, it may be simply a staphyloma marking the site of 
an old injury or idiopathic inflammation, or it may indicate the position of 
an intra-ocular tumor. If the latter, oblique illumination, the light being 
concentrated on the protrusion, will not illuminate the interior of the eye. 
If the protrusion is staphylomatous, light passes freely through the thinned 
membranes and the interior is illuminated. 

The Length of the Eye can be approximately determined by the dis¬ 
tance from the height of the scleral curve to the cornea. The patient is 
directed to turn the eye strongly inward, while the examiner observes it 
from the outer side. In hypermetropia the equator is nearer and in myopia 
it is farther from the cornea than in the normal eye. 

The Cornea is viewed without turning the lid and normally is trans¬ 
parent. Any pathologic condition is evidenced by a loss of this property. 
Its diameter can be determined by Priestley Smith’s keratometer, which 
consists of a millimetre scale placed between two plano-convex lenses in 
the form of an eyeglass having a focal length of ten inches; or it can be 
measured with the ophthalmometer. 


EXAMINATION OF THE EYE. 


93 


Hemorrhage into the layers of the cornea is a condition rarely found 
and generally comes from trauma. 

Opacities of the cornea often require minute examination for their 
detection. Daylight is first used, and light is concentrated on the cornea 
by a double convex lens. The same is done with artificial light. A super¬ 
ficial opacity is called a nebula; a dense one, a leucoma; a vascular one, 
pannus. Ulceration, interstitial inflammation, abscess, pressure, and for¬ 
eign bodies will cause opacities. The presence of a vascular keratitis will 
call for an immediate eversion of the lids and a search for trachoma bodies. 
The cornea may be clear, but protruding at its centre (keratoconus). It 
may be immensely enlarged as part of the disease known as hydrophthal- 
mos. Sometimes opacities are present in it at birth. 

In examining the cornea the following methods may be employed:— 

(A) The patient is placed facing a window, an outline of which will 
be seen reflected on the cornea. Any irregularity or opacity will cause a 
distortion of the image of the window. 




Fig. 81.—Diagram to sliow focal (or oblique) illumination. 


(B) Focal illumination is a valuable method. A double convex lens 
of two or three inches’ focus is used to concentrate the light from a lamp 
upon the cornea; or the same object can be attained by the use of the 
candle-lamp of Priestley'Smith. Another method is to reflect light from 
the ordinary head-mirror. Pegardless of the method used to concentrate 
light, it is advisable to view the cornea through a magnifying glass. 

(C) The concave retinoscopy mirror of twenty-five centimetres’ focus 
can be used to concentrate daylight or artificial light on to the cornea. 

(I)) Placido’s disc is used. The patient is placed with his back to a 
window and the examiner reflects light from the disc on to the cornea, the 
observer looking through a small hole in the centre of the disc. Nebulas 
will cause a distortion in the image. The disc can also be used with 
artificial light. 

(E) In case an nicer or abrasion is small, its outline can be obtained 
by the use of a solution of fluorescin (2 per cent.), which is dropped on 
the cornea. Any part of the cornea denuded of its epithelium will be 
stained a bright-green color, while the normal tissue will be unaffected. The 

















94 


MODERN OPHTHALMOLOGY. 


previous use of cocain increases the staining power of fluorescin. Valuable 
as is the fluorescin test, it is not infallible. Benson has found that fre¬ 
quently fluorescin would not stain some conditions commonly called ulcers; 
and, on the other hand, it would stain many corneas where neither ulcers, 
epithelial abrasions, nor pathologic conditions of the epithelium were dis¬ 
coverable. 

(F) The ophthalmometer can be used to determine the radius of 
curvature of the different meridians of the cornea, as will be explained 
later. 

(G) To determine the sensitiveness of the cornea, which is much 
reduced in glaucoma and in some diseases of the fifth nerve, take a small 
wisp or string of absorbent cotton and touch the cornea, taking care not 
to touch any other part. 



Fig. 82.-—Placido’s disc. 


(II) The corneal microscope, or the binocular magnifier of Jackson, 
can be employed to detect minute changes in the cornea, anterior chamber, 
and iris. Jackson’s instrument is designed to give a true binocular image 
magnified in all directions. It consists of two tubes with convex lenses at 
their convergent ends, and prisms at the divergent ends. 

The Anterior Chamber should be examined as to its depth, the clear¬ 
ness of its contents, and the possible presence of a foreign body or of an 
exudation. The depth of the chamber is estimated by observing the rela¬ 
tionship of the iris to the anterior surface of the cornea. Normally it 
averages 2.6 millimetres. Like a brook, when clear, the chamber is deeper 
than it looks. Normally it is shallower in infants and in the aged than 
in middle life. Pathologically the anterior chamber may be empty, too 
shallow, or too deep. When empty, the iris is in contact with the posterior 
surface of the cornea. A wound or a perforation from an ulcer will then 


EXAMINATION OF THE EYE. 


95 


be found. The chamber may be obliterated in an old case of iridocyclitis, 
in glaucoma, intra-ocular tumor, or in epibulbar sarcoma and hydroph- 
thalmos. 

A shallow chamber occurs in abnormally flat cornea, in traumatic 
cataract with swelling of the lens, in glaucoma, and in intra-ocular growths. 
It also is met with in an early stage of senile cataract when the lens is 
swollen. A deep chamber occurs where the cornea is too protuberant; in 
case the iris is displaced backward, as in adhesions between the pupillary 
margin of the iris and the capsule of the lens, the latter being drawn 
backward by the contraction of old cyclitic membranes. It also is present 
in serous cyclitis and in aphakia. The chamber may be shallowed or 
abolished at the periphery and be abnormally deep at the centre, as is 
sometimes observed in iritis, hydrophthalmos, and in cyclitic eyes. Adhe¬ 
sions between the cornea and iris can be determined either by ordinary 
inspection or by oblique illumination. 

Normally the aqueous humor is invisible. Pathologically it may be 
mixed with blood, pus, or lymph. Fluids in the chamber gravitate accord¬ 
ing to the position of the patient. Minute dots on the posterior surface 



Fig. 83.—Jackson’s binocular magnifier. 


of the cornea from a deposition of lymph are found in serous cyclitis. 
Foreign bodies in the anterior chamber can be seen by oblique illumination. 
The history of the accident will assist in the determination of their nature. 
If of iron or steel, the electromagnet will be of assistance in their removal. 

The Iris can be readily examined if the cornea and aqueous humor 
are clear. The color of the iris, its lustre, its movements, and its contour 
should all be observed. A lack of lustre and a change in color, together 
with a sluggish or immobile pupil, will indicate iritis. A localized bulging, 
with surrounding discoloration, may come from a foreign body, an intra¬ 
ocular tumor, a parasite, or a gummatous iritis. 

Tremulousness of the iris can be elicited by having the patient move 
the eye rapidly up and down, halting suddenly at the middle line. It 
indicates a want of support, and is found when the zonula is relaxed or the 
lens absent, dislocated, or shrunken. The condition can generally be 
observed easily by daylight. Sometimes it is better seen in a dark-room 
by oblique illumination. 

The Pupil should be carefully studied in all ocular cases, since it fur¬ 
nishes much information not to be obtained elsewhere. The size of the 






9G 


MODERN OPHTHALMOLOGY. 


pupil can be measured by the use of the pupillometer, which the observer 
holds close to the outer eanthus. The disc is turned until an aperture is 
found corresponding to the size of the pupil. The record is made in 
millimetres. 

Inequality of the pupils rarely occurs in health. It is found where 
one eye is blind, in disease of the teeth, in traumatism producing minute 
tears in the sphincter of the iris, in tabes, cerebral syphilis, disseminated 
sclerosis, paretic dementia, epilepsy, and probably in a few other condi¬ 
tions. Inequality alternating from one side to the other occurs as a pre¬ 
monitory sign of insanity. 

Mobility of the iris is determined by placing the patient in front of 
a window facing the light. He is to look at a distance. The examiner then 
covers the eyes for a moment; on uncovering, the pupils should be found 
larger, but should immediately contract. In case the iris is immobile and 
the tension of the eye is normal, a mydriatic should be used to determine 
whether adhesions are present. If the pupil oscillates between dilation 
and contraction, the condition is called hippus. This is a rare state, which 
Knies says “is observed in recovering paralysis of the motor oculi, and is 
then associated with nystagmus. It is much rarer as an independent con¬ 
dition, and is then found almost always in diseases—such as tabes, multiple 
sclerosis, etc.—in which there are frequent lesions in the region of the 
nuclei of the ocular muscles.” 

Contraction of the Pupil, miosis, may come from (1) irritation 
or (2) paralysis. 

I. Miosis from Irritation is caused by :— 

(a) Diffuse inflammatory conditions of the brain and meninges, caus¬ 
ing a direct stimulation of the motor oculi nerve. 

(b) Tumors near the anterior corpora quadrigemina or near the centre 
of the third nerve or in its fibres. 

(c) In the first stage of apoplexy, in hysteria, and in epilepsy. 

(d) In hemorrhage into the pons. 

(e) After long-continued near work, causing spasm of the ciliary 
muscle and sphincter of the iris. 

(f) Inflammatory conditions of the anterior portion of the eye (kera¬ 
titis, iritis, cyclitis, etc.) and foreign bodies in the cornea and conjunctiva. 

(g) After the use of eserin, pilocarpin, arecolin, muscarin, nieotin, 
or opium. 

II. Paralytic Miosis , due to the sympathetic nerve, occurs in:— 

(a) Injuries, apoplexy, tumors, inflammations of the cervical cord. 

(b) Mediastinal tumors and carcinoma of the esophagus. 

(c) Paralysis of the sympathetic nerve, and after excision of the 
superior cervical ganglion. 

Dilation of the Pupil, known as mydriasis, can be divided into two 
types: (1) paralytic and (2) spastic. 

I. Paralytic Dilation , dependent on the oculomotor nerve, occurs in:— 


EXAMINATION OF THE EYE. 


97 


(a) Hemorrhage or tumor in the floor of the aqueduct of Sylvius. 

(b) Iu diseases which affect the fibres of the motor oculi nerve any¬ 
where in their course ( e.g., sinus-thrombosis and glaucoma). 

(c) After the use of atropin, duboisin, daturin, hyoscyamin, hyoscin, 
or homatropin. 

(d) In crushing of the eyeball. 

II. Spastic Dilation, dependent on the sympathetic, is found in:— 

(a) Fright. 

(b) Accumulation of C0 2 in the blood. 

(c) In the fully-developed epileptic and eclamptic attack. 

(cl) Tumors and inflammations of the spinal cord (e.g., in the early 
stage of tabes). 

(e) Eeflex action from the presence of worms in the intestine; in 
lead and biliary colic. 

(f) In tumors of the neck. 

(g) Melancholia and mania. 

(h) After the use of cocain. 

(i) In labor and all painful irritations of any part of the sympathetic, 
such as renal colic, etc. 

Facts Concerning Pupillary Eeaction. —In miosis due to irrita¬ 
tion, light, accommodation, convergence, and eserin will cause still greater 
contraction; atropin will produce dilation. 

In miosis arising from paralysis, light, accommodation, convergence, 
and eserin will cause contraction; atropin has but little effect. 

In paralytic mydriasis there is no reaction with light, accommodation, 
or convergence; eserin acts but feebly. 

In spastic mydriasis, light, accommodation, convergence, and eserin 
will cause contraction. 

Abnormal Varieties of Pupillary Eeaction. — These are the 
Eobertson phenomenon, the liemianopic iris-inaction of Wernicke, the 
cortical reflex of Haab, the skin reflex, and Gifford’s contraction. 

The Robertson Symptom is this: the pupils contract on convergence 
or accommodation, but either do not react to light or do so feebly. This 
sign is brought out by first finding (by covering and uncovering the eyes) 
that the light-reflex is absent or feeble; next, the patient is told to look 
at an object placed at ten inches’ distance from the eyes. The pupil will 
be found to contract. It occurs frequently in tabes and general paralysis 
(two diseases due largely, if not entirely, to syphilis), and has been observed 
in senile dementia, multiple sclerosis, cerebro-spinal syphilis, epilepsy, 
lead poisoning, progressive muscular atrophy, aortic aneurism, hemiplegia, 
nuclear ophthalmoplegia, and chorioiditis. 

The Iris-inaction of Wernicke occurs in some cases of hemianopsia, 
and is valuable in localizing the lesion causing half-sight. A beam of light 
is thrown on the blind half of the retina. If the pupil does not contract, 
the lesion is in front of the corpora quadrigemina: i.e., in the optic nerve. 


98 


MODERN OPHTHALMOLOGY. 


chiasma, or optic tract. If the pupil contracts, the lesion is posterior to 
the corpora quadrigemina: i.e., in the optic radiations or cuneus. 

Wernicke’s symptom, to be of value, must be carefully sought for. In 
a dark-room a plane mirror is used to illuminate the eye feebly. With a 
concave retinoscopy mirror light is to be thrown obliquely into the pupil, 
first on the blind side, then on the other, and the result is recorded. 

The Cortical Reflex of TLaab occurs when the patient sits in a dark- • 
room and, on thinking of a bright light, the pupil contracts. 

The Shin Reflex is a dilation of the pupil, which occurs when a cuta¬ 
neous nerve is pinched. 

Gifford’s Reflex (known also as Galassi’s or the Westphal-Piltz reac¬ 
tion) is elicited by holding the lids open by a speculum. When the patient 
attempts to close the lids the pupil contracts. It is used to determine 
whether the sphincter of the iris is paralyzed. 

The Pupillary Area is to be examined by oblique illumination. Search 
is to be made for adhesions of the iris to the capsule of the lens, for exuda¬ 
tions, and for pigment-spots. 

The crystalline lens is examined (1) by oblique illumination; (2) 
by the ophthalmoscope or preferably by the concave retinoscopy mirror; 
(3) by illumination through the sclera. The mirror of the ophthalmo¬ 
scope is generally oblong, while the retinoscopy mirror is round and large 
(diameter, 1 to 2 inches) and gives a better illumination. 

Search is to be made for opacities or foreign bodies. Opacities viewed 
by oblique illumination appear grayish or whitish on a black background; 
if seen with a mirror, they are black on the red fundus. Only those opaci¬ 
ties can be observed which correspond to the pupillary area. To examine 
the periphery of the lens the use of a mydriatic will be necessary. In the 
selection and use of a mydriatic the examiner should be guided by the rules 
given elsewhere in this chapter. 

Foreign bodies often lodge in the lens, where they can sometimes be 
seen. Generally they are obscured by rapid swelling of the lens-substance, 
and their presence can be demonstrated by the use of x-ray photography 
after the method of Sweet or of Davidson. Occasionally oblique illumina¬ 
tion will show a rent in the capsule of the lens caused by the foreign 
body. Small bodies may lodge in the lens and remain for years without 
giving rise to trouble. 

After looking at the lens by the oblique method the observer is to use 
direct ophthalmoscopy, placing a convex glass of 10 D. strength behind the 
mirror of the ophthalmoscope. This enlarges the parts. If the lens is dis¬ 
located, colobomatous, or if an iridectomy has been made, the observer can 
see the margin of the lens. Sometimes the suspensory ligament and tips 
of the ciliary processes are visible. 

The Crystalline Lens.—There are two methods of examining the lens: 
(1) oblique illumination, and (2) the rise of the ophthalmoscopic mirror. 
Opacities in the lens appear grayish when seen by the oblique method; if 


EXAMINATION OF THE EYE. 


99 


observed by transmitted light they look black on a red background. To 
examine the peripheral parts of the lens the use of a weak mydriatic, such 
as mydrin, euphthalmin, or homatropin, will be necessary. Foreign bodies 
can often be detected by the use of focal illumination, but may be hidden by 
the opacity following their entrance. Euptures can often be seen by focal 
illumination. In using the ophthalmoscopic mirror at close range for the 
minute study of the lens it will be necessary to place a convex glass of 10 
to 20 I). strength behind the mirror. If part of the iris is congenitally 
absent or if a peripheral iridectomy has been made, it is possible to see the 
ciliary processes, the suspensory ligament, and the edge of the lens. 

The Vitreous Humor.—The lens being clear, the anterior part of the 
vitreous can be examined by the oblique method. Practically the ophthal¬ 
moscope is necessary in the examination of this humor. 

With a dilated pupil gross changes can be seen by using a concave 
retinoscopy mirror of twenty-five centimetres’ focus. If the vitreous is 
opaque in spots, it will be necessary to determine whether the opacities 



A, Opacities seen by reiiected light. B, The same by transmitted light. 


are floating or fixed. The patient is told to move the eye quickly up, then 
down, and he is then to stop suddenly at the middle line. This will cause 
floating bodies to move. This maneuver shows large opacities plainly, but 
small, dust-like spots can best be seen by the direct method of ophthal¬ 
moscopy. Fixed opacities must be studied by the same method. The 
localization of foreign bodies in the eye by the use of the x-rays has come 
to be of great value. 

The Ciliary Body.—The condition of this part of the eye is discovered 
by inspection and palpation. Tumors growing here often produce bulging 
of the corneoscleral region. If inflammation of the ciliary body is present, 
pressure through the intervening lid will cause tenderness and pain. 

The Tension of the Eye is determined in the following manner: The 
patient is told to close the eyes and look downward. The examiner, sitting 
in front of the patient, places his index finger on the upper lid and presses 
on the eye at the anterior scleral region. The pressure is applied by one 
index finger while the other rests steadily on the lid. If the eye can be 
dimpled by moderate pressure, the tension is said to be normal (Tn). 

L Of C, 





100 


MODERN OPHTHALMOLOGY. 


Abnormally, tension may be either increased (plus tension) or decreased 
(minus tension). In recording the findings the following divisions and 
abbreviations are used :— 

Tn = normal tension; T -{- ? = probable increase; T -j— 1 = tension 
perceptibly increased; T -f- 2 = tension markedly increased; and T -j- 3 
= eye of stony hardness. 

The degrees of minus tension are correspondingly recorded in this 
way:— 

T — ?, T — 1, T — 2, and T — 3. 

Tonometers—instruments constructed on the principle of the manome¬ 
ter—are used in physiologic laboratories for recording ocular tension, but 
are of little value clinically. 

The educated touch (tactus eruditus) is necessary in correctly esti¬ 
mating tension. The student should avail himself of all opportunities for 
proficiency in this line. 



Fig. 85.—Method of taking the tension of the eye. 


Physiologists have found that normal intra-ocular tension equals from 
26 to 28 millimetres of mercury. 

Tension, as a rule, is increased in glaucoma, in intra-ocular tumors, 
and occasionally in iritis. It is decreased, as a rule, in detachment of the 
retina, in perforations of the globe, in liquefaction of the vitreous humor, 
and in pseudo-neuroepithelioma. 

The Orbit.—The position of the eyeball should claim attention. If 
too prominent, it may he luxated or simply too protuberant. Luxation 
is present when the exophthalmos is so great that the globe has left the 
orbit entirely and lies in front of the septum orbitale. It is caused by 
trauma. A less degree of protrusion is called exophthalmos , and is found 
in orbital tumors and in suppuration in sinuses adjacent to the orbit. It 
is present in Graves’s disease, in paralysis of several orbital muscles, in 
inflammation of ‘Tenon’s capsule, and in general inflammation of the 
orbital tissues. It may be caused by the presence of foreign bodies in the 
orbit. Exophthalmos can be measured by comparing the diseased with the 
healthy side. 


EXAMINATION OF THE EYE. 


101 


In exophthalmos clue to the growth of a tumor in the orbit the finger 
may be used as a probe and often the neoplasm can be felt. In case an 
aneurism is present the finger may feel the pulsation and the phonendoscope 
will elicit the bruit, not only at the base of the orbit, but also over a con¬ 
siderable area of the skull. The accessory sinuses, frontal and ethmoidal, 
the nasal cavity, antrum of Highmore, roof of the mouth, and upper 
pharynx should be examined in any case of exophthalmos. In doubtful 
cases of tumor of the orbit, or of the adjacent parts, electric transillumina¬ 
tion should be employed. 

The presence of foreign bodies buried in the orbit can be determined 
frequently by the use of the x-rays. 

Enophthalmos , a sinking of the eye, results generally from trauma, 
but may be an idiopathic affection proceeding from lesion of the cervical 
portion of the sympathetic nerve. Atrophy of the orbital cellular tissue 
with loss of fat, loss of water due to cholera (von Graefe), and abscess of 
the orbit are causes. The extent of enophthalmos may be judged by com¬ 
paring the diseased with the sound side. 

Balance of the Ocular Muscles.—The various extra-ocular muscles are 
delicately balanced under normal conditions. The tendency of the recti 
to draw the eyeball backward is opposed by the action of the obliqui. At 
rest, the anatomic position of the eyes is naturally divergent, owing to the 
direction of the orbits and the optic nerve and the natural length of the 
muscles. The deviation of sleep, however, is immediately succeeded on 
waking by the functional position of rest, in which the visual axes become 
parallel. To maintain this position is easy and natural for the individual 
when the muscles are properly balanced. If one muscle or set of muscles 
is weak, an increased innervation is required to maintain the normal bal¬ 
ance. There are many tests of the muscle-balance, but only those most 
generally used will be described. First, however, it is necessary to mention 
definitely the terms which have been applied to the anomalies of the muscle- 
balance. These names were proposed by Stevens:— 

Orthophoria, normal adjustment of the ocular muscles. 

Heterophoria, abnormal adjustment of the ocular muscles. 

Hyperphoria, a tendency of one eye to rise above its fellow. 

Hypophoria, a tendency of one eye to fall below its fellow. 

Exophoria, a tendency of the visual axes outward. 

Esophoria, a tendency of the visual axes inward. 

Hyperexophoria, a tendency of the visual axis of one eye to deviate upward and 
outward. 

Ilypoexophoria, a tendency of the visual axis of one eye to deviate downward 
and outward. 

Hyperesophoria, a tendency of the visual axis of one eye to deviate upward and 
inward. 

Hypoesoplioria, a tendency of the visual axis of one eye to deviate downward 
and inward. 

Cyclophoria (Savage) is a want of equilibrium of the oblique muscles. 


102 


MODERN OPHTHALMOLOGY. 


The tests for muscle-balance are to be carried on at 20 feet and 13 
inches, respectively. The test objects are a lighted candle for distance, 
and a white dot on a black field for near. The surgeon should employ (1) 
the cover test, (2) the fixation test, (3) the Maddox rod, (4) the von Graefe 
test, and (5) the Maddox double prism. The cobalt-blue glass test is used by 
some surgeons. These tests are to be used while the patient possesses his 
full accommodative power: i.e., before a mydriatic or cycloplegic is em¬ 
ployed. 

The Cover Test is applied by having the patient look at a distant 
object placed in the median line on a level with the eyes. An obturator 
is placed alternately over the eyes, and the surgeon observes the position 
and movement of the eye at the instant of uncovering. A movement inward 
indicates that the eye has deviated outward (exophoria). A movement 
downward means hyperphoria. The test is repeated at thirteen inches. 

The Fixation Test. —The patient is told to observe the surgeon’s 
finger placed at 13 inches from and on a level with the eyes. The finger 



Eig. 86.—The Maddox rod. 


(Courtesy of D. V. Brown.) 

A, The single rod. B, Multiple rod. 


is then advanced slowly toward the patient’s nose to within 3 1 / 2 inches 
(8 centimetres). If one eye turns outward, there is exophoria. The test 
is a rough one, and its chief value is in determining which of the interni 
is the weaker. 

The Maddox I!od is practically a cylinder. It causes a luminous 
point to appear elongated, as a line or streak. When placed vertically before 
the right eye, the other being uncovered, the image of the light seen by the 
right eye becomes a streak. The Maddox rod test is used in the examination 
for both vertical and horizontal deviations. It is used at 20 feet, in a 
dark-room, and forms a reliable, rapid, and inexpensive test. The instru¬ 
ment is on the market in two forms: (1) the single rod, and (2) the 
compound rod. The latter consists of a series of rods joined laterally. 
The former must be carefully centred to be in line with the visual axis; 
with the compound rod little care is necessary in the adjustment. In 
normal conditions the streak made by the rod passes directly through the 


































































































































EXAMINATION OF THE EYE. 


103 


luminous point; if it deviates to the right or left, or is placed above or 
below the light, heterophoria exists; and the prism which corrects the faulty 
position of the streak is the measure of the heterophoria. This test shows 
esophoria to be a more common condition than exophoria. 

Testing for horizontal deviations is carried out as follows: The patient 
is placed 20 feet from and on a level with an electric light or gas-jet covered 
with a ground-glass globe. The room is darkened. Let it be supposed that 


1 2 3 



Fig. 87.—Diagram to show the Maddox rod test for horizontal deviations. 
The rod is in front of the right eye. J, Orthophoria. 2, Esophoria. 3, Exophoria. 


the Maddox rod is carefully adjusted over the right eye, the rod being placed 
horizontally in a trial-frame, and the left eye being free. The patient looks 
at the flame and informs the surgeon of the location of the vertical streak 
of light. If it passes directly through the light, orthophoria exists; if the 
streak is to the right there is latent convergence (esophoria) ; if it is to 
the left, there is latent divergence (exophoria). 

In testing for vertical deviations the rod is placed vertically before one 


Fig. 88.—Diagram to show the Maddox rod test for vertical deviations. 

o © 



The rod is in front of the right eye. 1, Orthophoria. 2, Eight hyperphoria (the upper image 
belongs to the left eye). 3, Left hyperphoria (the upper image belongs to the right eye). 


eye. In orthophoria the streak will run horizontally through the centre of 
the light. In case the streak passes below the light (the rod being in front 
of the right eye) there is right hyperphoria; if above, left hyperphoria is 
present. 

The yon Graefe Test is made by producing vertical diplopia by 
placing a 7 ° or 8° prism vertically in front of one eye and then looking 
with both eyes at a dot and line on a piece of paper held at the reading dis- 































104 


MODERN OPHTHALMOLOGY. 


tance or at an electric light at 20 feet. When using this test at 20 feet the 
patient in orthophoria will see two lights, one directly beneath the other. If 
heteroplioria exists there will be a lateral displacement of the images. The 
prism, base in or out, which causes the images to occupy the normal posi¬ 
tion (one directly beneath the other) is the measure of the esophoria or 
exophoria. 

1 2 3 




Fig. 89.—The von Graefe test, used at the reading distance. 

1, Orthophoria. £, Exophoria. 3, Esophoria. The prism is placed base up before the 
right eye. The lower image belongs to the right eye. 


If used for testing muscular equilibrium for near, the patient should 
look at a line in the centre of which is a dot. In orthophoria the line will 
appear elongated and two dots will be seen. In heteroplioria two lines and 
dots are seen, the lower set being to the right or the left. 

The Maddox Double Prism is used in one of the simplest tests of 
the ocular muscles, and is not only of value in testing the recti, but, accord- 



Fig. 90.—The Maddox double prism as a near test. 


ing to Savage, is of use in determining insufficiency of the oblique mus¬ 
cles. The instrument consists of two weak prisms (3° or 6°) placed base 
to base in a metal rim which is of standard size to fit into a trial-frame. 
The double prism is to be placed horizontally before one eye in such position 
that the line of junction of the two prisms will be on a level with the centre 
of the pupil. On looking through the instrument (placed before the right 


























EXAMINATION OF THE EYE. 


105 


eye, for example) three images will be seen: one higher and one lower than 
the real image, which is seen by the left eye. To distinguish the real image 
it is well to place a red glass in front of the left eye. On looking at a 
distant object, such as a flame, the instrument being placed horizontally, 
vertical diplopia is produced. If the muscle-balance is normal the three 
images will be on a line (Fig. 91) ; if esophoria is present, the red light 
will go to the left; if exoplioria exists, it will pass to the right. If hyper¬ 
phoria of the left eye is present the red light will move downward. In 
left hypophoria the red light moves upward. In the same way the right 
eye can be tested by changing the position of the double prism and red 
glass. 


.. V ' 

$ 



Fig. 91.—Use of the Maddox double prism for far. 

The prism is in front of the right eye, a red glass being placed over the left one. The 

real image is the middle one, and is red. M, Position of the red light in left esophoria. 

T, In left esophoria. 

To measure the amount of the muscular error the surgeon can place 
prisms of increasing strength before the eye bearing the red glass, with 
base in, out, up, or down, as the case may require, until orthophoria is 
established. 

The double prism can be used as a near test for the muscle-balance, 
the patient looking at a line and square, or dot, placed horizontally at the 
reading distance. Thus, in Fig. 92, 1 represents the line and dot; 2, the 
appearance of the same in orthophoria; 3, left esophoria, 4, left exophoi ia, 
5, hyperphoria; 6, hypophoria; 7, hypoexophoria, and 8 , hyperexophoria. 

^Savage has proposed to test the oblique muscles by the same means, 
using a Maddox double prism, each segment of which is of 6° strength. 






106 


MODERN OPHTHALMOLOGY. 


Insufficiency of the obliques is shown by the lack of parallelism between 
the middle line and the others. With the instrument in front of the 
right eye, the other being uncovered, if the right ends of the middle and 
lower lines converge (2, Fig. 93) there is insufficiency of the superior 
oblique; if the right ends of the superior and middle lines converge (2, 
Fig. 93), the inferior oblique is assumed to be too weak. It is necessary 
to state, however, that many eminent ophthalmologists do not accept 
Savage's views, but regard the phenomena as physiologic. 

The Phorometer and Eotary Prism. — These are valuable and 
necessary instruments for the rapid measurement of muscular insufficiency. 


2 . 

Q= 

Q= 


5. 

o 

o 

Q 

6 . 

o 

D 


3. 

o 


[ 



Q= 

=o 


O 


Q.— 1 c==D 


O 


O 


=D 

o= 


Fig. 92.—Diagram to show use of the Maddox double prism for near. 


Stevens’s phorometer (phorometer, “a measurer of tendencies”) consists of 
two rotating discs, each carrying a prism .of 5°. Each disc possesses a 
border of cogs, and a gear-wheel placed between the two discs causes them 
to move in unison. A scale, increasing from the centre each way from 0° 
to 8°, gives the strength of the refracting angle of the prism used. The 
essential part of the instrument is mounted on a leveling arm supported 
by a shaft and tripod. A locking device permits the arm to be lowered when 
the instrument is not in use. The leveling is secured by a micrometer-screw 
(F, in Fig. 95). In using the instrument the slide is placed in the groove 
of the phorometer, the face of the instrument being away from the patient. 
The side marked IUI., LIT., will then be before the patient’s right eye; 
































































































EXAMINATION OF THE EYE. 


107 


while the other side, marked ES., EX., will be before the left eye. After 
leveling the instrument, in testing for hyperphoria the pointer is placed 
at 0°, and the patient looks straight through the prisms at a flame placed 
at a distance of 20 feet. He sees two images of the flame. If these images 
are on a level, the muscle-balance is normal. If one image is higher than 
the other, the prisms are rotated until the images are made level. The 



2 4 

Fig. 93.—Diagram to show the use of the Maddox double prism 
in testing the oblique muscles. 

1, Insufficiency of left superior oblique. 2, Insufficiency of left inferior oblique. 3, Insuffi¬ 
ciency of right superior oblique. 4, Insufficiency of right inferior oblique. 

pointer then indicates the form and amount of the manifest hyperphoria. 
If the rotation is made slowly a greater amount of error will be recorded 
than if the prisms are moved rapidly. In examining for esophoria and 
exophoria. the pointer is to occupy the vertical position. Normally the two 
images will be on the same vertical line. If one is displaced to the right 



Fig. 94.—Stevens’s improved rotating prism slide. 


or left the adjustment is made as before until the images occupy the same 
vertical line, and the amount of insufficiency is read off by the scale on the 
side marked ES., EX. Other phorometers have been devised by Wilson, 
Lewis, and Verhoeff. 

The Rotary Prism .—For rapid work in the measurement of muscular 
imbalance the rotary prism of Cretes or the revolving prism of Risley is 



































108 


MODERN OPHTHALMOLOGY. 


useful. These instruments consist of two superimposed prisms of the same 
strength, provided with a mechanism which turns them in opposite direc¬ 
tions. When the apices coincide the strength is double that of each single 
prism. When the apices are opposite the prisms neutralize each other. 



Fig. 95.—Stevens’s phorometer ready for use. 
A, Support. F, Micrometer-screw. E, Spirit-level. 


Between these points any degree of deviation can be obtained, and thus the 
instrument replaces a whole battery of prisms. When in use it is placed in 
a trial-frame and the patient looks at a flame twenty feet distant, the other 
eye being uncovered. A scale registers the amount of error. 



Fig. 96.—Risley’s rotary prism. 

(Courtesy of D. V. Brown.) 

Power op the Ocular Muscles. —Having described the reliable tests 
for muscular imbalance, it is necessary to speak of adduction, abduction, 
and sursumduction. Adduction (prism-convergence) is measured by find¬ 
ing the strongest prism before one eye, the base of the prism being toward 
the temple, with which the patient can see a flame single at 20 feet. The 












EXAMINATION OF THE EYE. 


109 


examination is begun with the use of a 15° or 20° prism, the strength 
being increased until double vision occurs. The other eve, of course, is 
uncovered. Normally adduction varies from 30° to 50° or 60°. Abduc¬ 
tion (prism-divergence) is similarly tested, the base of the prism being 
toward the nose. It amounts to 6° or 8° of prism. Stevens states that 
the ratio between adduction and abduction should be 6 to 1, but Risley 
believes that in emmetropic or carefully corrected eyes it is often as 3 to 1. 
Sursumduction (sursumvergence) is the power of uniting the image of a 
flame seen through a prism which is placed vertically before one eye while 
the other is uncovered. The examination is begun with a weak prism, 1 / 0 ° 
to 1°. It usually amounts to 3°, but may reach 10°. The amount oi right 
sursumduction is equal to the strongest prism, placed base down before the 
right eye or base up before the left, through which the patient can see the 
test-object single. The amount of left sursumduction is ascertained simi- 
laih !>} placing the prism base down before the left eye or base up before 
the light. Right and left sursumduction should be equal. 



Fig. 97.—Prism-holder. (Noyes.) 


It is necessary to state that, if the patient has an error of refraction, 
this must be carefully corrected before the final deductions are made from 
the examination of the muscles. It is valuable practice, however, to 
examine and record the muscular condition before as well as after the 
examination of the refraction. 

Measurement of Muscle-power for Near Points. —In measuring 
the power of the ocular muscles for near, square prisms are used and the 
patient is directed to look at a point or cross placed at a distance of 13 or 
14 inches. Noyes’s prism-holder (Fig. 97), which is graduated into inches 
or centimetres and metric angles, possesses a slider carrying test-cards, and 
is a useful instrument. In the prism-holder before each eye are three 
spaces into which square prisms can be fitted. Recently Hulen has devised 
an improved prism-holder which permits adjustment of the interpupillary 
distance and can be attached to the phorometer (Fig. 98). In all cases in 
which the examination of the muscle-power in accommodation is made, the 
proper reading glasses must be used. These are called “tests in accom- 
















110 


MODERN OPHTHALMOLOGY. 


modation,” and they are made on the same principle as the tests for dis¬ 
tance. In place of the flame or electric light at 20 feet the line-and-dot 
test of von Graefe is used at 14 inches. 

The Tropovieter is an instrument for the measurement of the rotations 
of the eyes. Its inventor, Dr. G. T. Stevens, holds that this determination 
is important, since he believes that strabismus (convergent or divergent) 
is often due to excessive tension upon the vertically acting oculiir muscles 
independently of abnormal tension upon the internal and external recti. 
He considers that many conditions of heterophoria can be similarly ex¬ 
plained. 

The tropometer “consists essentially of a telescope in which the inverted 
image of the examined eye is found at the eyepiece, where, either as an 
aerial image or as an image upon the ground glass, its movements can be 



Fig. 98.—Prism-holder. (Hui.en.) 


accurately observed. A graduated scale in the eyepiece permits every 
movement of rotation, in any direction, to be exactly measured.” 

The scale (Fig. 100) is thus described: “The long line between and 
at right angles to the shorter lines divides two similarly graduated scales 
running in different directions: the larger circle represents the outer border 
of the cornea, the edges of which are in contact with the two strong lines; 
the interval between each pair of short lines of the scale is ten degrees of an 
arc, commencing at the strong line in each case. If, now, the head of the 
person examined is held firmly in the primary position and the eye caused 
to rotate strongly in a given direction, the arc through which the border 
of the cornea passes may be accurately read upon the scale.” In Fig. 100 
the curved dotted line represents a new position of the border of the cornea. 

“Suppose that the person examined has been directed to look strongly 










EXAMINATION OF THE EYE. 


Ill 


upward, then the cornea has moved down the scale and reaches the point 
in this example of 40°, that being the measure of this rotation. By means 
of the small lever the scale can be placed horizontally, vertically, or 
obliquely, and by means of the two graduations measurements in opposite 
directions can be made/’ 

Use of the Tropometer .—In determining upward rotation the border 
of the cornea is made to coincide with the strong line which ajipears in the 
upper part of the scale at the right hand. 

The adjustment is made by means of the milled head at the side of the 
standard. As the eye rotates up, the image moves apparently down. In 
determining the downward rotation the strong line at the lower left-hand 
side of the scale is taken as the point of departure. 



Fig. 99/ —Tropometer. (Stevens.) 


For lateral rotation the scale is turned to the horizontal position and 
the corresponding strong lines are used as before. 

In order to adjust the upper border of the cornea on the line, it will 
generally be necessary for the examiner to place the left hand upon the 
forehead of the patient and make gentle traction of the upper eyelid by 
the thumb. This application of the hand to the forehead is advisable in 
all measurements, as by this means the examiner is able to detect even a 
slight movement of the head, which would vitiate any measure of the rota¬ 
tion. In adjusting the head to the head-rest the teeth should be closed and 
the line of the upper lip just below the nose should be in a vertical line 
below the glabella, or ridge just above the root of the nose. 




































112 


MODERN OPHTHALMOLOGY. 


According to Stevens, the most favorable rotations are: upward, 33°; 
downward, 50°; inward, 55°; outward, 50°. 

The Clinoscope .—An instrument called the clinoscope has been de¬ 
signed by Dr. Stevens for the testing of muscular insufficiencies. It con¬ 
sists of two tubes, each three centimetres in diameter and fifty centimetres 
in length, which are mounted on a metal platform. The tubes can be 
rotated horizontally and the amount of rotation is marked by a pointer and 
scale. The clinoscope is a valuable laboratory instrument. It is used 
in determining the declination of the meridians in paralysis of the ocular 
muscles, and in anomalous adjustments of the eyes as regards the horizontal 
visual plane. Stevens also uses it to determine the power of torsion and to 
increase torsional power by exercise. 




70 - 

40 - f - 

20 ' 

M - 

\ 

io /x" 

N/ 

/ 




Fig. 100.—Scale ol the tropometer. 


Strabismometry.—Squint can be measured by any one of the following 
methods: (1) by the perimeter; (2) the cover, or screen, test; (3) 
Priestley Smith’s tape-measure test; (4) Hirschberg’s test; (5) the linear 
measurement test; and (6) the prism test. Other valuable tests have been 
devised by Swanzy and Maddox. 

1. Measurement by the Perimeter. —In using this method, which, 
unfortunately, is not admissible in very young children, the requisites are 
a perimeter and a lighted candle. The arc of the perimeter is placed 
transversely across the visual axis of the deviating eye; both eyes are kept 
open and the normal eye fixes the middle line of the instrument. The 
surgeon now moves the lighted candle along the arm of the perimeter until 
the image of the flame is opposite the centre of the pupil of the deviating 
eye. The degree on the perimeter is then read off, thus giving the angle 
of the strabismus. While this will answer for practical purposes, to learn 






















EXAMINATION OF THE EYE. 


113 


the total angle of the squint requires that the angle gamma be measured and 
added to the angle of the strabismus. The angle gamma is the angle formed 
by the line of fixation with the optic axis. A perimeter and lighted candle 
being provided, the patient is seated as above, and fixes with the deviating 
eye, the other being covered. Following is Lang’s description of the pro¬ 
cedure : “The flame is moved along the arc in the same way as when ascer¬ 
taining the angle of the squint. If the candle is behind the fixation-point 
when the image of the flame falls in the centre of the pupil, then there is 
no angle gamma; but if the candle is. to one side of the point of fixation, 
when the image is opposite the centre of the pupil, then there is an angle 
gamma. The degree on the arc against which the candle now rests indi¬ 
cates the amount of the angle; if the candle is on the temporal side of 
the eye, the angle is positive, and if it is on the nasal side, the angle is 



Fig. 101.—Measurement of strabismus by the perimeter. 


negative. When adding the amount of the angle gamma to the angle of 
the squint to ascertain the total angle of deviation the positive and nega¬ 
tive signs of the angle gamma must be treated mathematically; therefore 
the former increases and the latter diminishes the angle of deviation.” 

2. The Cover, or Screen, Test.— The patient looks at a small dis¬ 
tant object; the “good” eye is covered with a card, while the squinting eye 
fixes the object; a strabismometer is now placed on the lower eyelid with 
the zero mark coincident with the centre of the pupil of the uncovered 
eye. The “good” eye is now uncovered and fixes the object while the 
squinting eye turns, the amount of deviation being noted. This test is 
applicable to all ages. 

3. Priestley Smith’s Tape-measure Test.— The requisites are a 
dark-room, a lamp, an ophthalmoscopic or retinoscopic mirror, and a double 
tape two metres long. One-half of the tape is black, the other half colored. 


8 










114 


MODERN OPHTHALMOLOGY. 


The colored half is divided into 12 parts, numbered in multiples of 5, 
from 5 to GO. and attached to its end is a small weight to keep it taut 
while in use. At the end of the black tape is a ring and another is placed 
at the junction of the black and colored portions of the tape. The following 
is the method of measurement (A. E. Davis) :— 

“The patient holds the end of the black tape against his face directly 
under the non-squinting eye, while the observer stands directly in front of 
him with the ring attached at the other end of the tape over his thumb or 
ophthalmoscope, which he holds in front of his eye. The patient looks 
directly into the ophthalmoscope, from which a light is reflected into the 



Fig. 102.—Measurement of convergent strabismus of 
right eye by Priestley Smith’s method. 

squinting et r e. It will be noted that the image of the light from the 
ophthalmoscope will be to the outer side of the centre of the cornea in 
convergent squint and to the inside of the centre of the cornea in divergent 
squint. The observer now takes hold of the colored tape at the ring, the 
edge of the hand being held toward the patient for the patient to look at, 
and lets the tape slide between his fingers, carrying it in a direction opposite 
to that in which the eye squints. Both eyes should follow the hand, and, 
when the squinting eye has turned sufficiently for the image of the light 
from the ophthalmoscope to occupy the centre of the cornea in that eye, 
stop the hand and note the distance it has moved along the tape. The 




EXAMINATION OF THE EYE. 


115 


number on the tape indicates the degree, or angle, of the squint. This 
method has the great advantage that it can be used on very young children.” 

Fig. 102 may assist in the understanding of the method. Let R and 
L represent, respectively, the right and left eye. The right presents con¬ 
vergent strabismus. The surgeon places the tape (A-E) in position before 
non-deviating eye, then throws light on to R , and sees the reflex eccen¬ 
trically outward, which shows that this eye deviates inward. Then holding 
the graduated part of the tape, he moves it outward (at the same time 
moving the mirror) until the reflex is in the middle of the pupil. The 
axis of the deviating eye, R, will have moved from S to E , through the 
angle S-o-E. The axis of the non-deviating eye, Z,, will have moved 
through an equal angle, E-A-T. The angular movement of L , as measured 
by the tape-line, equals the angular deviation of R. 

4. Hirschberg’s Test. —This test estimates the amount of strabismus 
from the position of a candle-flame reflected from the cornea. The surgeon 
holds the lighted candle one foot in front of the patient, who has both eyes 
open. While the image of the flame is in the centre of the cornea of the 
fixing eye, it is eccentric to the pupil of the other eye. If the pupil meas¬ 
ures 3.5 millimetres, and the image of the flame is midway between the 
centre of the pupil and the pupillary margin, the squint is less than 10°; 
if it is seen at the pupillary margin, the amount of squint is 12° to 15°; 
if it is midway between the pupillary margin and corneal limbus a squint 
of 25° is present; if the flame shows on the margin of the cornea the 
amount is 45° to 50°; and if on the sclera, 60° to 80°. This test is 
sufficiently accurate for practical purposes, and can be used on any case. 

5. Linear Measurement Test. — This requires a strabismometer 
(Fig. 103), marked in millimetres. The patient looks at a distant object 
while the surgeon makes on the lower lid a vertical mark corresponding to 
the outer margin of the cornea of the squinting eye. Then the normal eye 
is covered and the patient looks at the same object while the surgeon again 
marks the outer margin of the cornea. The distance between these marks 
(distance from S to R in Fig. 104) is measured in millimetres and recorded. 

6. The Prism Test can be used only when binocular vision is present 
(he., in early cases and in patients in whom binocular vision has been 
restored by treatment). The requisites are a frame, a set of prisms, a 
colored glass, and a lighted candle placed at 20 feet. The colored glass 
is placed in front of the better eye and the patient looks at the flame. 
If diplopia (double vision) is present, note is made whether it is homony¬ 
mous or crossed; and the prism, which produces single binocular vision, 
divided by two, is the measure of the strabismus. Thus, in homonymous 
diplopia which requires a 30° prism, apex inward, to produce single binocu¬ 
lar vision, there is a convergent squint of 15°. 

Keratometry (Ophthalmometry; Astigmometry).—By these terms is 
meant the act of measuring the curvature of the cornea and the determina¬ 
tion of the difference of curvature in different meridians: i.e., the meas- 


116 


MODERN OPHTHALMOLOGY. 


uring of corneal astigmatism. Instruments for this purpose (keratometers, 
ophthalmometers, astigmometers) consist of a telescope, carrying a metal 
arc movable around its axis; a head-rest, for the support of the patient; a 
leveling screw, by which the telescope can be raised or lowered; a Wollaston 
prism, placed between two achromatic objectives, which serves to double 
objects in a direction parallel with the plane of the metal arc; a Bamsden 
eyepiece with a spider’s thread; two white objects (mires), each of which 
is carried on an arm of the arc; and another arc which registers the posi¬ 
tion of the meridians of greatest and least refraction. These parts are 
diagrammatically shown in Fig. 105. In using the astigmometer a reliable 
source of illumination, such as gas or electric light, is required, and is 
generally best furnished by four Welsbach burners or the same number of 
incandescent lights. The author prefers gaslight, for the reason that the 



Fig. 103.—Strabismometer. 



Fig. 104.—Linear measurement 
of strabismus. 


intensity of the light can be controlled. The principle on which the 
instrument is based, that of doubling, has been borrowed from astronomy 
and can only be referred to here. Originally the invention of Helmholtz, 
who used it solely as a laboratory instrument, the astigmometer has been 
made a clinical necessity by the labors of Javal and Schioetz. One of the 
mires is a parallelogram; the other has the special form of “insteps,” each 
of which corresponds to one dioptre. 

In making the examination only the central portion of the cornea 
is inspected—the part forming an area extending about 1.2 millimetres 
in every direction from the visual line. Hence it is necessary that the 
patient should look directly ahead into the barrel of the instrument and 
hold the eye in a fixed position. The telescope is then focused by a 
to-and-fro movement. On looking through the astigmometer the surgeon 
will see four images of the two mires: the outside images are to be ignored, 








































EXAMINATION OF THE EYE. 


117 


"the central images are to be studied. One of the mires is fixed, the other 
is movable on the arc. The mire at the right is to be moved until the 
central images touch at their bases (Fig. 106). Then the instrument is 
to be rotated 90° on its axis and the relations of the images noted. If 
they overlap, astigmatism is present and each step thus covered represents 
1 D. of error. If the images separate, astigmatism “against the rule” is 
present, and can be measured by causing the images to touch at their bases 
and then turning the instrument back 90°. If the images retain their 
relation, the bases touching, there is no corneal astigmatism. 



Fig. 105/—Schematic section of the Kagenaar model of the 
Javal-Schioetz ophthalmometer. (Kagenaar.) 

A, B, Transverse section of the mires. A', B', The same seen on the flat. C, D, Ob¬ 
jectives. E, Spider’s thread. G, G, Metal arc. H, Ocular. J, The doubly refracting 
prism. K, Metal tube. L, Arc divided into degrees. 

While inspecting the cornea by this instrument it will often be noticed 
that the images move slightly, sometimes overlapping, then separating, 
showing that the curvature of the cornea can be changed by the tension 
of the recti muscles. This circumstance explains why the ophthalmometer 
often registers 0.50 or 1.00 D. more astigmatism than is actually present 
as demonstrated by retinoscopy and trial-lenses. In the case of a quiet 
patient, and in the hands of a competent observer, the discrepancy between 

























118 


MODERN OPHTHALMOLOGY. 


the amount of astigmatism found by the instrument and the glass accepted 
by the patient will generally be surprisingly small. 

The astigmometer accomplishes several things: 1. It registers the 

amount of astigmatism and gives the axes of the principal meridians. 2. 
It unerringly detects corneal nebulse or opacities causing irregular astig¬ 
matism. 3. It gives a magnified view of the iris. It does not tell whether 
the astigmatism is myopic or hypermetropic. Tor the examination of the 
deaf and dumb, children, and illiterates it is an absolute necessity, and 
for the rapid and correct determination of refraction in all other persons 



Fig. 106.—Appearance of the mires in the primary position. 

(Kagenaar.) 


it is useful. Although many ophthalmometers are on the market, the 
author prefers the one here described. The recent model of the Javal- 
Schioetz instrument, provided with a large disc on which confusing circles 
and figures are found, is not so valuable as the model of 1889. 

Testing Visual Acuity.—The sense of sight consists of (1) the form- 
sense (visual acuity), (2) the light-sense, and (3) the color-sense. 

Testing the Form-sense.— By the term “form-sense” is meant the 
power which the eye possesses of distinguishing form, after the refraction 
has been corrected, if it be abnormal. 



Fig. 107.—Appearance of the mires in the secondary position, 
showing four dioptres of astigmatism. (Kagenaar.) 

Having finished the external examination, it will next be in order to 
test the visual acuity of the patient. In this form of examination every¬ 
thing depends on the answers of the patient. Hence in malingerers, illiter¬ 
ates, and children this test is of doubtful value. 

In order to make the examination of visual acuity of value, a definite 
standard is necessary. This was supplied many years ago by Snellen, whose 
test-types are in general use. They are so constructed that each letter is 
formed within a scpiare, each side of which is divided into five equal parts. 
The sizes of the letters are such that the normal eye will see them at certain 













EXAMINATION OF THE EYE. 


119 


definite distances under a visual angle of five minutes. Each of the five 
small squares is seen under a visual angle of one minute, which is supposed 
to be the minimum visual angle for the normal human eye. In order to 
subtend the same visual angle it is necessary that the letters used as tests 



should increase in size in proportion as the distance from the eye increases 
(Fig. 108). 

The Snellen test-types are shown in Fig. 109. Although they have 
been generally accepted as the standard, it has been found that letters con¬ 
structed under the angle of five minutes do not always give the best visual 


C B 

L N 

P T E R 

F Z B D E 

O F L C T G 

APEORFDZ 
HPRTVZBDFHKO 

VITAOIOlVPIf 

Fig. 109.—Snellen’s test-type. Fig. 110.—Wallace’s test-type. 




’ F B ' 

“AH 1ST 

' E T L F * 
*Z E R P B“ 

• O D C G H N “ 
“ SYVRBA w 

• EKZEFNHP •> 

• BFRPNHZA *•* 

.• VYKKOOCO U 



acuity of which the patient is capable, many eyes possessing vision 5 / 4 of 
this standard. Hence, test-types have been constructed on the basis of an 
angle of four minutes. 

The test-type of Wallace is constructed on the four-minute basis. Some 
objection has been raised to the intervals between the lines in Snellen’s 










120 


MODERN OPHTHALMOLOGY. 


types. This has caused Monoyer to construct a series of lines based on the 
decimal system in which the interval between each line is 1 / 10 and the 
degrees run from 0.1 to 1.0. These types were highly commended by Noyes. 

The letters used as tests are printed in black on a heavy white paper 
or painted on porcelain, or, as is now preferred by many surgeons, the 
letters are white with a black background. It is claimed for the latter 
that a white letter on the black card is not so tiring to the eye as the 
ordinary test-type. 

For recording visual acuity Snellen furnished the formula: V = 

In this V stands for vision, d indicates the distance of the patient from 
the type, and D the distance at which it should be read. 

Acuteness of vision is found by determining the smallest type which 
can be read at 6 metres. Rays of light coming from an object at this dis- 



Fig. 111.—Improved trial-frame. 


tance are assumed to be parallel. In the practical use of test-types it is 
necessary to have a steady and equal illumination. Since daylight does not 
answer these requirements, it is best to use artificial light. A reflector is 
used to throw the light from a gas-bracket on to the type. The patient, 
being placed at the proper distance, is requested to read the letters, begin¬ 
ning with the largest. The eye not under examination is covered with a 
metal disc placed in a frame for holding lenses, commonly known as a 
“trial-frame’'’ (Fig. 111). 

If the patient correctly reads the line which the normal eye reads at 
6 metres, vision should be recorded as follows: RE = 6 / e . The left eye 
is then tested in the same manner. If, for example, this eye reads at 6 
metres only the line which should normally be read at twice this distance, 
vision should be recorded as LE = 6 / 12 . Attempts are then to be made 
to render the vision normal by placing a spheric or cylindric lens, or a 












EXAMINATION OF THE EYE. 


121 


combination of the two, in front of the eye. The result is recorded as part 
of the case history. Regardless of whether normal vision is attained by 
lenses or without them, it is necessary in many cases, particularly in persons 
under forty years of age, that a mydriatic be used in order to examine the 
refraction properly. Before proceeding to its use, however, it will be 
advisable to examine the near vision, the light-sense, the color-sense, the 
field gf vision, the muscle-balance, and the intra-ocular tension. 

In case the patient cannot read the largest letters on the test-type at 
6 metres, he is to be led toward the letters, and, when the top letter is 
recognized, a note is made of the distance. If, on closely approaching the 
test-type, it is found he cannot read any letters, the surgeon is to determine 
whether the eye under examination can see fingers at a few inches. Should 
there exist inability to recognize fingers, it will be necessary to find whether 
light-perception, PL, exists. This can be done by taking the patient into 
a dark-room and throwing a faint light upon the eye by means of an oph¬ 
thalmoscope or retinoseope. The mirror can be turned so as to illuminate 
different parts of the retina, and the intensity of the light can be varied. 
The result of these observations is to be recorded for future comparison. 
Light-perception may be qualitative or quantitative. If qualitative, the 
patient will distinguish between two sheets of paper, one of which is 
entirely white, the other with printing on it. If quantitative, he will recog¬ 
nize the difference between a dark and a lighted room. 

Up to this point it has been supposed that the patient is an adult of 
average intelligence. If he be illiterate, the surgeon must make use of 
specially constructed test-types. A common one is that designed by Snellen, 
in which the letter E is placed in various positions and the patient is to 
place a metal E } which he holds in his hand, in the same positions as obtain 
on the test-type. Another test is that of Burchardt who arranged a series 
of dots of different sizes, in the -form of groups. The latter is a more 
exacting test. Still another way is to have pictures of animals or common 
objects printed according to the visual angle. Such test-types have been 
designed by Ewing and Wolffberg. While they are not scientifically exact, 
these test-types are of practical value. As regards the examination of malin¬ 
gerers, the subject is of such importance as to demand consideration else¬ 
where in this chapter. It may be remarked here that in the examination 
of the refraction of illiterates, malingerers, and children, credence is to be 
given to the findings obtained by ophthalmoscopy, ophthalmometry, and 
retinoscopy. 

Examination of Near Vision. —This includes the testing of the 
ability of the patient to read print: i.e., the condition of the accommoda¬ 
tion. The test-types for near vision are those of von Jaeger and Snellen. 
The No. 1 of the former corresponds to Snellen’s 0.50. A very valuable 
card for the near test has been designed by Oliver, and consists of five 
divisions (Plate VI). Each division is composed of several columns, each 
made up of three or four words. This author describes his test as follows: 


MODERN OPHTHALMOLOGY. 


1 22 
± <V/V 

“Each word is composed of three or four letters constructed in strict con¬ 
formity with the Snellen basis of letter-formation; each column of words 
has a purposive succession of test-letters, so arranged as to be of value in 
the recognition of astigmatism; each grouping of letters is composed of 
series of words which bear no relation to one another; and each test-letter 
is surrounded by a space which is equal to, or greater than, the area that 
is occupied by the letter itself.” The letters are much clearer than those 
of the ordinary test-type, having been cut in steel. 

In the chapter on “Physiology of A r ision” mention has been made of 
certain terms used in describing the accommodative power (see page 68). 
The near point (P) can be found by ascertaining the closest point at which 
the patient can read fine type. Another method, and a valuable one, is by 
means of the hair-optometer, which is in common use in England, but is 
little known in the United States. This (Fig. 112) is an instrument 
resembling a miniature harp, in which the strings are replaced by hairs. 
It is provided with a handle and a hook, to which a dioptre steel tape can 
be attached. The steel tape is marked in dioptres on one side and fractions 
of a metre on the other. In testing the accommodation the surgeon is to 
proceed as follows: A trial-frame is placed on the patient and one eye is 



Fig. 112.—The hair-optometer. 


covered with a metal disc. In front of the other eye the glass needed to 
make vision 6 / 6 , in the test for far, is to be placed. The patient holds the 
hair-optometer in front of a white background and brings the instrument 
to the nearest point at which the hairs can still be distinguished. The 
distance from this point to the outer canthus of the eye is to be read off 
on the steel tape. This gives the amount of accommodation in dioptres. 

Suppose, for example, the nearest point at which the hairs can be 
clearly seen is 12 centimetres. The amount of accommodation is then 
100 /i 2 = 8 D. The other eye is then to be tested in a similar manner and 
the result is recorded. The amplitude of accommodation is determined by 
using the formula: A = P — E, in which P and R are expressed in 
dioptres. Suppose, in the case cited above, distant vision was made 6 / e 
by the use of a -f 1 D. spheric lens; P has already been found to be 8 D.; 
hence A = 8 — 1, or 7 D. 

After the age of forty the near point recedes, and the patient is said 
to be presbyopic. It then becomes necessary for reading purposes to add a 
convex glass to the lens which is needed to correct any error in refraction. 
The rule is to add 1 D. for every five years after the age of forty. Thus, 
at forty-five the patient wears a-f 2 D. lens. This rule, however, is always 










PLATE VI. 


o:o 


l c r T 
C O v t 

riti 

BOLL 


COOT 
CUT 
L O » S 

TILL 


V B L T 

C 1. O 9 

* # r T 
T 0 O U 


» « » * 

L O' C L 
• etc 

i rit 


D - 075 


coo 
r t J3 

O » 0 
fill 


LEE 
C 6 0 
C £ 1 
HOT 


O L » 
LET 
TOO 

r O E 


e l r 

TOD 

o r r 

COT 


0-100 


LOTT 


L E E T COLT 

Test-words for the Determination of Accommodation, 

TOLL toli> fool 

dole fell r l o e 


(□liver,) 


50 


CODE 

FLED 

COLD 


DOLT 
L O O T 
DOLL 


0-200 


FED 

ODE 

LOT 


LOO 
TOE 
O F T 

















,PI tfTAJT 



-ir noted in strict con- 

‘ l v 'i v ■> OJ IffU 

■a*. a column of words 


a, -d as to be of value in 


ug f letters is composed of 

Vi 

‘it; and each test-letter 

■i spac e wi dch.ie 

tower than, the area that 

f 1 0" It elf/" ) 

t. ‘ much cl-'.irer than those 

' -t;, 1 -iving !,c> i 


, r on “ Pit vsic-1 g >' 

iention lias been made of 

i d scribing • i 

alive power (see page 68). 

• 

* r : •lining- the closest point at which 

■ cun re.v.1 fine type. Aiwih* 

m-udiod, and a valuable one, is by 

} utomn ■ • v. '■ ' •.' - 

n • orumon use in England, but is 

n n lb* 1 ( laved .States. 

: 112) is an insrrument 

g a iyiiaufre harp, "m wfciel 

: the si. rings are replaced by hairs. 


: <ivd :« ' -iud'' u.ni) 6 book, to which a dioptre steel tape can 
’ i ft t- ■•■{ >:ipv - marked in dioptres on one side and fractions 
< or, • r' otic < It; toning the accommodation the surgeon is to 
- fo ;! .,-v.s: A triai-ir true is placed on the patient and one eye is 


(.HavijCI 





.w-lssT 


at if> 


Fig. 1*2.-- The hair-optometer. 

h a metal disc. Ii front of the other eye the glass no, led to 
» " V., in the tesj or far, is to he placed. The pat: mt holds the 
''''i in front of a wl.it*.- background and brings th< instrument 
r, -t point at which the hairs can still be distinguished. The 
o'! this point to t e < .t r :at)ius of the eye is to he read off 
,oo. This g - :'count of accommodation in dioptres. 

' ■ *° r evarap g />• p"in.t at which the hairs can be 
If oc-Ti '' i■ f ; e amount of accommodation is then 
‘he other r- then to :•»<» tested in a similar manner and 
• i , . t*••<•■. rded. Tic :i.'hjihi";tde of accommodation is determined by 
!ormula: A ! - it, in which I* and R are expressed in 

o ppose, in the ca.se cited above, distant vision was made */e 
i a -4- 1 D. spin:no lens; 1 has already been found to be 8 D.; 
— 1, or 7 D. 

■ the age of forty the near point recedes, and the patient is said 
-byopie. It then becomes necessary for reading purposes to add a 
-- to the lens which is needed to correct any error in refraction. 
- to add 1 D. for co-ry live years after the age of forty. Thus, 
ice patient we- rs a -f 3 D. lens. This rule, how-.nor, is always 


I>. 


VO 








D -050 


LETT 

COOL 

r c c l 

POLL 


COOT 

r c r t 
LODE 
TELL 


FELT 

CLOD 

LETT 

TOOL 


T O O P 
LOLL 
P O T E 
CELT 


D -0.75 


COO LEE 
TEE COD 
ODD EEL 
ELL DOT 


OLD E L P 

LET TOD 

TOO o r r 

r O E COT 


D-IOO 


L E E T CO 

FOLD F E 

TOLL TO 

DOLE F E 


D = I 

CODE 

FLED 

COLD 


L T LOFT 

ED DELL 

L D FOOL 

L L FLOE 


50 

DOLT 

LOOT 

DOLL 


D =2 OO 


FED LOO 

ODE TOE 

LOT OFT 





EXAMINATION OF THE EYE. 


123 


secondary to the following absolute injunction: Never give a patient read- 
ing glasses which magnify the print. The glasses for near work should 
render the object sharp and clear; they should not enlarge it. The subject 
of presbyopia will receive further consideration in the chapter on “Re¬ 
fraction.” 

Measurement of Convergence. —Convergence is the power of direct¬ 
ing the visual axes to a near point. It is brought about chiefly by the 
contraction of the internal recti. There is generally a close relationship 
between convergence and accommodation, although accommodation may be 
paralyzed and convergence be unaffected. Far and near points have been 
mentioned in connection with accommodation, and the same terms are used 
in describing convergence. The far point of convergence is the point at 
which the visual lines are directed when convergence is at a minimum, 
as when the eyes are directed toward an object 6 metres or farther away. 
The near point of convergence is the point at which the eyes are directed 



Fig. 113.—Measurement of the near point. 


when turned inward to the greatest degree. It is evident that when the eyes 
are directed to a distant object the visual axes are parallel. If the lines 
diverge, they can meet only when projected backward; hence the term 
negative convergence. This is determined by finding the strongest abduct¬ 
ing prism (apex of prism being toward the temple) with which the patienc 
can overcome double vision when looking at a flame 6 metres distant. In 
the practical application of the test the patient keeps both eyes open, the 
prism being placed before one eye only. This gives in degrees the amount 
of negative convergence. 

The term metre-angle has been used, and must now be explained. 
When the eyes converge to a point directly in front of them, and 1 metre 
distant, the amount of convergence toward the middle line is called 1 
metre-angle. If they are directed to points 1 / 2 , x / 4 , or 1 / 8 of a metre dis¬ 
tant, the convergence is, respectively, 2, 4, and 8 metre-angles. Likewise, 
when directed to a point 2 metres distant, the convergence is recorded as 





124 


MODERN OPHTHALMOLOGY. 


V, metre-angle. Accommodation for the near point is called positive con¬ 
vergence, and is found by having the patient hold a hair-optometer at a 
distance of 25 centimetres from his nose. Both eyes are to look at a bead 
placed on one string of the optometer; and the instrument is advanced 
toward the patient until the bead appears double. When this point is ascer¬ 
tained the distance is read off by means of the dioptre steel tape and the 
number of metre-angles of convergence is recorded. The average normal e} r e 
shows as many metre-angles of convergence as of dioptres of accommodation. 
Thus, when the eyes are directed at a point distant 1 / i metre, the eye 
requires 4 D. of accommodation and 4 metre-angles of convergence. The 
relationship thus existing in normal eyes is much changed in ametropia. 
The hypermetropic eye calls on its accommodation before convergence is 
necessary. In the myopic eye the reverse is the case. 

The pow r er to maintain convergence is determined by the use of the 

gold bead on the optometer and a shield. The patient holds the optometer 

at the distance required in his work and looks at the gold bead with both 

eyes. The surgeon now covers one eye with the shield, which is immediately 

removed and the effect noted. If there is no movement of either eve con- 

%/ 

vergence is maintained properly (orthophoria). If one or both eyes move 
when covered, and then move back to the primary position when uncovered, 
there is heterophoria. Its amount can be found by the following method: 
A word cut from Snellen’s smallest test-type is pasted on a piece of white 
card. A vertical line is drawn through the centre of the word. A trial- 
frame is used; a prism of 6°, base up, is placed before the right eye. The 
word and line are looked at with both eyes and are seen doubled. The lower 
image belongs to the right eye, and should be seen immediately under the 
upper. If it does not occupy this position, but is placed to the right or left 
of the upper image, the deviation is to be corrected by placing a prism hori¬ 
zontally of sufficient strength to cause the images to appear in proper 
position. 

In making a test of convergence it is necessary that a patient who 
wears glasses for near work shall have the lenses properly centred. If 
decentred, they will act as prisms and cause deviation. 

Perimetry.—Direct vision having been examined by means of test- 
types, it will next be in order to determine the state of indirect vision. 
Outside the fovea visual acuity declines rapidly. Thus, according to Ivonigs- 
hofer, 1° outside of it vision is 1 / 3 ; and at 2° or 3° it is 1 / 6 . In testing 
vision beyond the fovea attention is paid, not to acuity, but to form. This 
determination is known as perimetry. While it is true that a rough estimate 
of the visual field can be obtained by using the hand as a test-object, and 
a more reliable judgment can be had by mapping the field on a blackboard 
(Jeffries), or with the campimeter of de Wecker, yet the best method is 
the use of the perimeter. This instrument is either a hollow hemisphere 
or a metallic band representing one meridian of such a hemisphere. The 
latter is a graduated arc turning on a central pivot and bearing a movable 


EXAMINATION OF THE EYE. 


125 


disc. A recording apparatus registers the point at which the test-object is 
seen in different meridians. The perimeter of McHardy (Fig. 114), that 
of Priestley Smith, and that of Skeel are among the best of the self¬ 
registering instruments. Portable perimeters are of value, one of the best 
being Dana’s. 

McHardy’s perimeter is used in this manner: One eye of the patient 
is to be bandaged. The other is to be directed constantly at a small white 
disc placed at the centre of the pivot. The test-object (a white disc) is 
then to be carried- to the end of the arc and is made to approach the centre 
slowly. As soon as the patient sees it, the surgeon registers the point. The 
same procedure is followed in the upper, lower, inner, outer, and oblique 
meridians. r lo make the examination of value, at least three meridians 
should be tested in each quadrant. Then the points thus registered are 
connected by a line, and thus a map of the visual field for white is obtained. 



Fig. 114.—The McHardy perimeter. 

(D. V. Brown, Philadelphia.) 


The field for colors is tested in the same manner, a colored test-object being 
substituted for the white one. The apertures of the McHardy perimeter 
permit the use of a test-object of different sizes, 1, 2, 5, 10, 15, and 20 
millimetres sqilare. 

In ordinary perimetry the test-objects are comparatively large, sub¬ 
tending an angle of 2° to 4°, thus covering thousands of retinal elements. 
Such tests are rough as compared with the tests for visual acuity. Hence 
a method of perimetry has been introduced by Bjerrum which involves the 
use of white objects subtending a very small visual angle, the examination 
being made at a distance of 2 metres and upon a black screen 2 metres 
broad. The examination is begun at the ordinary distance (30 centimetres) 
with the 10-millimetre white square and continued at 2 metres with the 
3-millimetre disc. In the first case the visual angle is 10 / 3 oo and in the 
second 3 /» 000 , or 2° and 5', respectively. In the first instance the boundaries 









126 


MODERN OPHTHALMOLOGY. 


of the normal field are those given on page 78; in the second they average 
35° outward, 30° inward, 28° downward, and 35° upward (Berry). Thus, 
by the Bjerrum method the field is smaller; hence it is capable of giving 
valuable data for diagnosis. 

The form of the normal field is oval and its greatest extent is on the 
temporal side. In case the patient is amblyopic or cataractous the exam¬ 
ination is made by fixing one candle in the middle line while another is 
moved along the arc. The perimeter is useful in examining the angle of 
deviation in strabismus, as has been explained. 

Defects in the Visual Field are of two kinds: (1) the physiologic 
blind spot and (2) pathologic defects. The blind spot is found 15° to 
the outside of and 3° below the point of fixation. Pathologic defects may 
take the form of concentric contraction, hemianopsia, sector-like defects, or 
scotomata. Hemianopsia (half-sight) can often be made out by a rough 
test, such as the use of the hand. The other defects require careful perim¬ 
etry. While a full consideration of hemianopsia is naturally out of place 
in this chapter, it may be well to state briefly that the dividing-line between 
the blind and seeing field may be horizontal or vertical. Vertical hemianop¬ 
sia may be homonymous, bitemporal, or binasal. If homonymous, both right 
or both lateral half-fields are absent. Absence of both right half-fields shows 
blindness in the left half of each retina, a condition to which the term 
‘Tight homonymous hemianopsia” is applied. Left homonymous hemianop¬ 
sia means blindness of the right half of each retina. In bitemporal hemi¬ 
anopsia both temporal fields are wanting, and in the binasal form the nasal 
half of each field is wanting. Further consideration of the subject will be 
found in the chapter on “Diseases of the Optic Nerve.” 

Concentric contraction and sector-like defects can be mapped out by 
the careful use of the perimeter. Scotomata are areas of partial or com¬ 
plete blindness lying within the field of vision. They are divisible into 
positive and negative, true and false, central and peripheral. A positive 
scotoma is present as a cloud which obscures vision in a certain direction 
and is due to retinal disease. A negative scotoma is a space in which 
objects naturally are unseen by the individual in health. The physiologic 
blind spot forms a negative scotoma. True scotomata are due to lesions 
in the brain, optic tracts, optic nerve, or retina, while false scotomata are 
caused by the obstruction arising from the presence of a blood-clot, an 
opacity in the dioptric media, or a new formation floating in the vitreous 
body. Such a defect changes its position with every movement of the eye¬ 
ball. Central scotoma is due to retinal or chorioidal disease; the toxic 
action of alcohol, tobacco, and other substances capable of producing am¬ 
blyopia; or to a form of neuritis involving the optic nerve behind the globe. 
Such scotomata are mapped out with difficulty because of impaired fixation. 

In all cases of scotomata it is to be advised that the surgeon, after 
determining the extent of the field, should use a small test-object, which 
is passed from the centre of the perimeter outward in many meridians. 


EXAMINATION OF THE EYE. 


12? 


Testing the Light-sense. —The testing of the light-sense was at one 
. time regarded as a scientific curiosity, but of late years it has come to occupy 
a practical place in ophthalmic examination. By the light-sense is meant 
the ability of the eye to distinguish different intensities of light. Two per¬ 
sons may have equal acuteness of vision,— i.e., equal space-sense,—and yet 
under feeble illumination one will not discern Snellen’s letters, while the 
other will read them. In this case the persons have a different appreciation 
of brightness: i.e., the light-sense (L) is different in the two. Instru¬ 
ments for the purpose of comparing the intensity of one light to another, 
which is taken as a standard, are called photometers. In the practical appli¬ 
cation of photometry it is the sense of stimulation, not the sense of contrast, 
which is measured: i.e., the power to distinguish the effect produced by 
the smallest possible quantity of light where the surroundings are dark. 
Since daylight is an uncertain quantity, photometers are constructed in 
such a way that the illumination is produced by a normal candle (one of 
one-candle power). The instruments of most widely accepted use are those 
of Forster and Henry. In the use of either it is necessary first for the 
patient to sit in a dark-room with bandaged eyes for ten minutes before¬ 
hand, in order that the retinae may become adapted to darkness. 

Forster’s photometer (Fig. 115) is a box measuring 1 / 3 meter by 1 / i 
meter by 1 / G meter. It is blackened inside, and provided with two apertures 
for the eyes to be tested. A window for the admission of light from a candle 
placed in a separate compartment, and black test-marks on a white ground, 
complete the apparatus. The test consists in finding the smallest apertures 
admitting the candle’s rays which will permit the recognition of the test- 
letters. The size of the aperture is recorded on a scale marked in milli¬ 
metres. Should one eye see the test with an aperture of 1 square millimetre, 
and a second eye see it only when the aperture is enlarged to 4 square 
millimetres, the second eye possesses functional power four times greater 
and a light-sense four times smaller than that of the first eye. 

The Henry photometer consists of a box provided with an aperture, 
a candle, and nine discs of opal. After the preliminary bandaging of the 
eyes, the eye not under examination being covered, and the head enveloped 
in the hood, “the opal discs are, one by one, removed, and the patient is 
told to say when he detects any light; should he detect it through seven 
opals his light-perceptive power is registered as 7; if through six, five, or 
four, etc., 6, 5, or 4 is entered; a note is also made of the sex and age of 
the patient, and the condition of the fundus” (Henry). 

The light-sense is diminished in many cases of general disease in which 
the blood is in a vitiated condition. It is often diminished in chorioidal, 
retinal, and optic-nerve diseases. 

Testing the Color-sense. —For the investigation of the color-sense, it 
is useless to ask the patient to name the colors. It is only by the process 
of matching colors that the color-sense can be rapidly and properly tested. 
There are three plans for the recognition of subnormal color-perception: 


128 


MODERN OPHTHALMOLOGY. 


(1) diiect comparison of pigment-colors; (2) direct comparison of spectral 
colors, and (3) the study of subjective after-color (complementary color). 
Of these, the first, for practical work, is the most worthy of consideration. 
The second method is not likely to become popularized, because of the ex¬ 
pensiveness of the apparatus, its liability to get out of order, the fact that 
spectral colors are not such as the patient daily observes, and the further 
reason that the use of the apparatus demands intelligence on the part of 
both the examiner and the person examined. Hence, pigment-colors must 
be used foi comparison. The third method is of value only in exceptional 
expert cases. 

The direct comparison of pigment-colors has been popularized by 
Holmgren, who borrowed the ideas of Seebeck and the worsteds of Wilson. 



Fig. 115.—Forster’s photometer. (Fick.) 

The instrument is here shown with the doors open. When in use 
they are closed. 


Holmgrens test, which has long had the prestige of authority and popu¬ 
larity, is not reliable. His colored plate explanatory of tests for color¬ 
blindness, which is found in many text-books of ophthalmology as a test, 
should not be used as such, since its colors are only intended to show the 
mistakes which a patient with subnormal color-perception might make. 
Among those who have shown the inefficiency of the Holmgren tests are 
Oliver, of Philadelphia; Edridge-Green, St. Clair Buxton, and G. A. 
Critchett, of London; and T. H. Bickerton and Karl Grossman, of Liver¬ 
pool. A llliams, of Boston, in one year’s work, found four patients who 
passed the Holmgren tests, but made so many mistakes with the reds and 
greens of the lantern test as to show them unfit for responsible positions. 
The fact is that the worsteds, whether used as described by Holmgren, or 
as modified in Thomson's stick, or in other devices, do not represent in any 


















































EXAMINATION OF THE EYE. 


129 


manner the actual working conditions under which color-vision is demanded. 
Ihe miniature lantern tests, while more nearly attaining accuracy, are open 
to the same objection. In fact, the ideal way to test the color-perception 
of railway and steamship employees, as has been shown by Oliver, is to 
examine candidates under their actual working conditions. The sooner 
this fact is recognized, the better for the traveling public. 

With reference to the determination of subnormal color-perception, 
the ophthalmic surgeon should divide his patients into two classes: (1) those 
who are to be tested as a matter of clinical routine, and (2) those who are 
employees of railway or steamship companies. It is evident that a method 
of examination which would answer for the first class would be entirely 
inadequate for the second. For general clinical purposes a scientifically 
arranged collection of loose wools is the best, cheapest, and most available 
material for practical use. The series devised by Oliver offers distinct ad¬ 
vantages over many tests, in that the candidate is made to expose his color- 
defect by handling a series of inexpensive wools. The colors in these 
wools have been made of equal relative intensity; the value of each color 
is expressed; the set is so constructed that it can be employed by any 
educated layman ; notes of the passing color-changes can be preserved for 
future comparison, and written expressions of the character and amount 
of the perception can be given. They have all been made of one grade 
of manufacture, dyed with vegetable material. Properly, he employs a 
black surface during the testing, which is done in the ordinary manner 
of having the candidate select the -nearest matches to the test-skeins, the 
designations of his choice being placed upon suitable blanks made for the 
purpose. 

In regard to the testing of the color-sense in marine and railway em¬ 
ployees, the candidate, as Oliver says, should be placed as nearly as possible 
under the actual conditions demanded by his vocation. It is evident that 
miniature lantern tests placed at fifteen or twenty feet, containing colored 
glasses of unknown ratios, while more valuable than the ordinary clinical 
tests, do not in any manner answer the requirements. The recognition of 
the colored signal must be made at a distance sufficiently great to permit 
the stoppage of a rapidly moving train, trolley car, or steamship. For this 
purpose Oliver has designed a fixed apparatus which can be used on any 
railway. The method is described best in his words:— 

“Wooden frames containing properly and proportionately sized match 
and confusion colors of bunting for daylight work, or illuminated plates 
and lanterns of transmitted color for bad weather or night, are to be lined 
in a row in any order whatsoever, just as the wools are promiscuously thrown 
upon a table. The five test-colors similar to the ones I have employed for 
the near tests are placed in an upper tier. Just as with the near-work tests, 
the candidate employs one eye at a time. This done, he is then made suc¬ 
cessively to designate by the actual position of the color in the lower line 
the nearest numerical match to each of the upper test-colors. This selection 


130 


MODERN OPHTHALMOLOGY. 


by number is to be handed to the examiner, who after having obtained the 
true color-names of the numbers chosen for the occasion by the attendant 
places the choosings upon suitable blanks for permanent registry. 

“To obtain the different percentages of light-stimulus and to simulate 
as nearly as possible changes in character of weather (fog, rain, etc.), vari¬ 
ously tinted glasses can be used, although preferably the candidate can by 
this plan be tested during the actual states of weather. 

“An experimental track with a number of open switches so arranged 
that the sidings pass directly beneath certain colors would be useful for 
practically testing the color-vision that is necessary to employ while run¬ 
ning locomotives, trolley cars, etc., at full and even high rates of speed. 

“In marine service the danger is increased. All vessels carry a green 
light on the starboard side, and a red light on the port, each being so boxed 
as to be seen forward and amidships. These are accompanied by a low white 



forelight, and sometimes by a high white aftlight. Hence, by comparison, a 
vessel’s course can be easily distinguished. If, under such conditions, how¬ 
ever, a heavy fog, or snow, or a rainstorm were to exist, it can be under¬ 
stood how an official with subnormal color-perception, judging these im¬ 
portant color distinctions by their intensities alone during the best of 
weather, is placed in a position that practically amounts to the absence 
of signals.” 

Lantern Tests. —Since many color-blind persons can pass the Holm¬ 
gren examination when placed at 1 metre distance in good daylight; and 
since such persons are dangerous when occupying responsible positions in 
railway, marine, and naval service, attempts have been made to produce such 
tests as will expose deficient color-perception in this class of individuals 
when placed under surroundings similar to those met with in their voca¬ 
tions. It has been assumed that such conditions can be imitated by the 











EXAMINATION OF THE EYE. 


131 


lantern tests. Lanterns for examining color-perception are used at a dis¬ 
tance of 5 metres. By means of discs containing apertures for colored 
glasses over which smoked lenses can be superimposed, an attempt is made 
to imitate the appearance of railway signal-lights. 

The lantern test will detect small defects in the color-perception of 
the central part of the retina which may be overlooked by the worsted tests; 
but, as has been said before, in the practical examination of railway em¬ 
ployees and sailors neither the worsted nor lantern test can insure satisfac¬ 
tory results. 

Measurement of Vision for Colors. —Apparatus for the quantita¬ 
tive estimation of the color-sense has been designed by Donders, de Wecker 
and Masselon, True and Valude, Oliver, and others. The examination is 
to be made by placing the patient at a distance of 5 metres and exposing a 
color through an aperture of definite size. The person is to name the color; 
if he cannot do so through the opening of standard size, the opening is 
enlarged until he is able to name the exposed color. Oliver’s apparatus is 



a convenient device for practical use. With it the patient, with normal 
color-sense placed at 5 metres, requires an opening exposing 2 2 / 3 milli¬ 
metres of surface for the recognition of red; 8 3 / 4 millimetres for blue; 
10 ®/ 4 millimetres for green; and 22 3 / 4 millimetres for violet. 

The Use of Mydriatics.—In many cases of suspected ocular disease it 
is impossible to make a complete examination without resorting to the use 
of certain medicines which act upon the iris or upon the accommodation, or 
upon both. Those which cause the iris to retract, thus enlarging the pupil, 
will be considered first; they are known as mydriatics. If they possess the 
property of paralyzing the ciliary muscle (accommodation), they are called 
cycloplegics. All of the latter class are mydriatics, but not all mydriatics 
are cycloplegics. Mydriatics are used for four purposes: (1) to dilate /the 
pupil and thus permit the examination with the ophthalmoscope; (2) to 
paralyze the accommodation and thus permit the observer to measure the 
refraction by some methods which can be employed only when the ciliary 
muscle is made inactive; (3) to determine the diagnosis of “eyestrain”; and 






























































































































































































































132 


MODERN OPHTHALMOLOGY. 


(4) they are employed as therapeutic agents in inflammations, particularly 
those of the uveal tract. 

The mydriatics employed by practical ophthalmologists are atropin, 
scopolamin, homatropin, duboisin, hyoscin, daturin, hyoscyamin, mydrinp 
and euphthalmin. 

Use of Mydriatics for Eefraction Purposes. —Mydriatics can be 
used in solid powder dropped into the conjunctiva, in oily menstruum, in 
gelatin discs, or, preferably, in freshly prepared solutions. In applying a 
solution of any mydriatic it is best to drop the medicine upon the upper 
part of the cornea while the patient is looking down, thus causing the solu¬ 
tion to spread over the cornea. Applied in this way, absorption of the drug 
occurs more rapidly and more powerfully than when dropped into the con¬ 
junctival sac. It is always advisable that the patient should turn his head 
downward and to the right when the physician applies drops to the right 
eye, and to the left when applied to the left eye, so that the excess will flow 
away from the lacrimal apparatus. 

An imperative rule is: Never use a mydriatic until after testing the 
tension of the eye, and never use a mydriatic if the tension is increased. 
Whenever possible, an ophthalmoscopic examination should be made before 
a mydriatic is used. ISTo one except a skilled physician should prescribe a 
mydriatic, for the weakest of these drugs has been known to cause out¬ 
breaks of glaucoma. Mydriatics are dangerous remedies in the very young, 
in the feeble, or the aged, and should be used with discretion at all times. 

Atropin, the best known of the mydriatic group, and the one whose 
effects last longest, is the active principle of Atropa belladonna. The pure 
atropin, owing to its slight solubility, has been replaced by the sulphate. 
For the purpose of examining the refraction, the use of the ophthalmo¬ 
scope, etc., p, solution of atropin of the strength of gr. ii-iv to the ounce 
is employed. A few drops of this are instilled into the conjunctiva, and 
a half-hour later the ophthalmoscopic examination can be made. If the 
refraction is to be measured, it will be best to have the patient use the 
solution thrice daily for three or four days. The medicine should be 
dropped into the outer part of the conjunctiva, or on to the outer part 
of the cornea, to prevent leakage into the nose and throat. Atropin solu¬ 
tions should be marked with a poison-label and kept under lock. The effect 
of atropin begins to pass off at the end of four days, and is completely 
recovered from at the end of two weeks. While in children and adults 
rapid dilation of, the pupil follows the use of atropin or homatropin, in 
infants the application of a mydriatic is often locally unsuccessful. Al¬ 
though the physiologic effects may be manifested by flushing of the face, 
dryness of the mouth, and accelerated cardiac action, the pupils may dilate 
but slightly or not at all. 

Scopolamin is found in belladonna-root, stramonium-seeds, and occa¬ 
sionally in Duboisia myoporoides. It is a much more powerful drug than 
atropin, and is used in solution in the strength of 0.1 to 0.2 of 1 per cent. 


EXAMINATION OF THE EYE. 


133 


In children and feeble persons solutions of the strength mentioned may 
cause rapid and irregular heart-action, staggering gait, dryness of the 
throat, and somnolence. The effect of scopolamin begins to disappear in 
twelve hours and is entirely absent after five or six days. 

Ilomatropin is a derivative of atropin, and is used in the form of the 
hydrobromate. It is much weaker than the mydriatics just mentioned, and 
its cycloplegic action is less reliable. Nevertheless, it is a valuable agent. 
It is used in a 2- or 2.5-per-cent, solution. To be efficient its use must be 
forced. A drop is placed in the eye to be refracted every five minutes for 
an hour; even in small doses it produces conjunctival irritation, while 
larger amounts will give rise to uveal and retinal disturbance (Stewart and 
Oliver). This is lessened and the desired action of the drug is assisted 
by the simultaneous use of a cocain solution. For making an ophthalmo¬ 
scopic examination a smaller quantity is necessary. The advantage of 
homatropin is that its effects wear off sufficiently in twenty-four or thirty 
hours to permit the patient to resume his vocation. Its great disadvantage 
is that in many cases, used in non-irritative amounts, it does not completely 
paralyze the ciliary muscle. As a therapeutic measure, if employed alone, 
it is without value in iritis and iridochorioiditis. It may cause staggering 
gait, partial collapse, and hallucinations, and in some cases prolonged 
mydriasis. 

Cocain produces a transient dilation of the pupil sufficient for the use 
of the ophthalmoscope, and a slight and transient paralysis of the ciliary 
muscle. 

Duboisin in the form of the sulphate is used in the strength of gr. ss 
to oij. Its mydriatic effect diminishes at the end of forty-eight hours and 
is entirely absent at the end of a week. As a cycloplegic it is much stronger 
than atropin and its effects disappear more rapidly. 

Hyoscin and Hyoscyamin are powerful mydriatics. They are said to 
possess marked toxic properties. Bisley finds that for ophthalmic pur¬ 
poses only the pure crystals of hyoscyamin are to be used, and the solution 
should be strictly neutral, filtered through neutral paper. The solution 
should not be heated. An untoward effect of hyoscyamin, used in undue 
strength, is the production of ciliary spasm causing intense pain. The pupil 
is widely dilated, but the ciliary muscle is not at rest. Under such circum¬ 
stances the use of atropin will relieve the pain and cause cycloplegia. 

Daturin in its physiologic action is very much like atropin, and can 
be used interchangeably. By some it is supposed not to have any effect on 
the secretion of milk, and hence it is used by them in nursing women. 

Mydrin is used for prompt dilation of the pupil without disturbing 
the ciliary muscle. It is a white, soluble powder composed of ephedrin 
hydrochlorid and homatropin hydrochloride: Vioo part of the latter to 1 
part of the former. A 10-per-cent, solution promptly dilates the pupil and 
has little or no effect on the accommodation. At the end of thirty minutes 
the pupil is widely dilated, and in from four to six hours the effect has 


134 


MODERN OPHTHALMOLOGY. 


disappeared. In young subjects there is no apparent loss of accommodation; 
in elderly persons there is often a transient ciliary paresis. It possesses 
two additional advantages: it is a time-saver and its strength is long 
preserved. 

Euphthahnin is used in 2-, 4-, or 10-per-cent, solution for ophthal¬ 
moscopic examination. It dilates the pupil in a half-hour, and its effects 
pass off in ten to twelve hours. It causes only a slight disturbance of vision. 

The Use of Miotics. —The agents used to contract the pupil are eserin, 
physostigmin, pilocarpin, and arecolin. The first three are used in strength 
of gr. ss to 5vj; and the last in from 1 / 2 - to 1-per-cent, solutions. Arecolin 
is the best miotic for general use. Eserin may produce intoxication, tonic 
convulsions, hallucinations, and delirium, particularly in aged and feeble 
persons. 

Ophthalmoscopy. —In 1851 Helmholtz predicted that by the use of 
the ophthalmoscope “all the pathologic changes in the retina and vitreous 
humor, so far observed only in the cadaver, can be seen in the living eye: 
a fact which promises great progress in the little-known pathology of the 
organ.” His ophthalmoscope, which was a very simple instrument, con¬ 
sisting of three plates of thin glass fastened together and mounted at an 
angle of 56° on a brass disc, has undergone numerous modifications and 
improvements. These have embraced all types, such as refraction, binocular, 
auto- and even demonstration instruments. Demonstration ophthalmo¬ 
scopes are useful laboratory instruments. Thorner’s stationary ophthal¬ 
moscope surpasses other instruments of its class in the combination of a 
large field, brightness of illumination, and absence of reflexes. This instru¬ 
ment is particularly valuable in that the ophthalmoscopic picture can be 
made visible to any person. 

Description of the Ophthalmoscope. —The ophthalmoscope prac¬ 
tically consists of a perforated mirror attached to a handle. The mirror 
presents a circular perforation at its centre, and is mounted on a swivel in 
order that it may be turned. The mirror need not be large for direct oph¬ 
thalmoscopy, since the useful part is a small area surrounding the perfo¬ 
ration. The sight-hole should be 3 millimetres in diameter. A small 
opening is more useful in studying the fundus, while a larger one is pre¬ 
ferred for the measurement of refraction. When the examiner and the 
patient are emmetropic, such a simple ophthalmoscope answers admirably 
for the examination of the fundus. In many cases, however, it is necessary 
to place a lens behind the mirror in order to correct the patient’s refraction. 
It is assumed that the surgeon is emmetropic; if not, he should wear suit¬ 
able glasses. Eor the purpose of carrying a number of lenses in a small 
space, rotating discs, which enable the surgeon to increase or decrease the 
lens-strength rapidly, have been designed. In this manner the myopia or 
hypermetropia of the patient can be rapidly corrected, the range of the 
lenses usually running from 0.25 D. to 23 D. Such instruments are called 
refraction ophthalmoscopes. Accompanying the instrument is a double 


EXAMINATION OF THE EYE. 


135 


convex lens of from 13 D. to 20 D. strength, for use in indirect ophthal¬ 
moscopy and to obtain oblique illumination. This lens should measure 
2 Vo inches in diameter and should be supplied with a handle. 

Every teacher of ophthalmology is often requested by students to 
specify his choice of ophthalmoscopes. It is perhaps unnecessary to say 
that all of the instruments on the market are useful and that good work 
can be done with any of them. The instrument of Loring is deservedly 
popular in this country and that of Morton is much used in Great Britain. 



Excellent instruments have been devised by Couper, Harlan, Jackson, 
Knauer, Knapp, Landolt, May, Pyle, Randall, Snell, and others. Detailed 
accounts of these ophthalmoscopes can be found in the catalogues of the 
instrument-makers. 

Methods of Use. —Not all of the light entering the pupil is absorbed 
by the chorioidal pigment; a certain amount returns from the eye. If the 
examiner’s eye is placed in the same position as that occupied by the source 
of illumination, or immediately behind it, the interior of the eye becomes 


















































































136 


MODERN OPHTHALMOLOGY. 


visible. This is the principle of the ophthalmoscope. A mirror in which 
a hole is cut is brought in front of the eye. The mirror, gathering rays 
of light from a point of illumination, becomes a secondary source of light 
which is projected into the dilated pupil. The observer’s eye, placed behind 
the mirror, receives these rays from the patient’s eye. 

There are two methods: the direct and the indirect. In the former 
the surgeon places his eye close to the patient’s eye and looks directly upon 
the much enlarged and upright details of the interior of the observed eye. 



Fig. 119.—Loring’s ophthalmoscope. 

(D. V. Bkown, Philadelphia.) 



In the latter he has the patient removed an arm’s length, and usually a 
convex lens is placed between the patient’s eye and the examiner’s mirror. 
The image obtained by this method is inverted and in the air. As the 
direct method gives a larger magnification it shows a smaller part of the 
fundus at one time; it is valuable for the study of minute changes and for 
the practical estimation of refraction. By the indirect method the portions 
seen are less magnified, and hence include a larger area. This plan is the 
better for obtaining a general idea of the condition of the fundus with the 


















EXAMINATION OF THE EYE. 


137 


location of any lesions. Refraction estimated by this method is both a 
complicated and an uncertain procedure. 

The direct method is explained in Tig. 120. Light from L is collected 
by the ophthalmoscope, 00, and reflected into the patient’s eye. It forms 
an illuminated spot at oo. From this rays pass to the retina of the examiner 



at 8. These rays, coming to a focus in the vitreous humor at F, diverge 
to form an image which extends from T to T. 

Tig. 121 explains the indirect method. Rays from the lamp, L, are 
reflected by the concave mirror, Oph, and brought to a focus at Z. These 
rays diverging from Z are made parallel by a convex lens (Lens). The 
rays are brought to a focus on the retina by the dioptric arrangement of 



the examined eye. The rays emerging from the patient’s eye follow the 
same path and will come to a focus at Z. At this point (Z) the examiner 
will see an inverted aerial image. 

The Room and Light. —Although many do not deem it necessary, 
the room in which the ophthalmoscopic examination is to be made should 
be entirely dark. The light is preferably obtained from an Argand burner 
















138 


MODERN OPHTHALMOLOGY. 


or a frosted electric bulb, and should be steady and clear. The burner 
should be mounted on a bracket permitting universal movements. 

Position of Examiner and Patient.— In using the direct method 
the surgeon should approach as closely as possible to the eye of the patient. 
The surgeon uses his right eye to examine the patient’s right. The source 
of illumination must be on the same side as the eye to be examined, and 
on a level with it. The mirror of the ophthalmoscope should be tilted so 
as to face the light. The patient is told to look straight ahead, keeping 
both eyes open and fixing a distant object on the wall in front of him, and 
holding his eyes still. The surgeon should then place the ophthalmoscope 
in such a position that its central opening will coincide with the pupil of 
the eye to be examined. The proper position of the patient, surgeon, and 
the ophthalmoscope are shown in Fig. 122. 

The surgeon should see the red fundus reflex, and, if the refractive 



Fig. 122.—Relative positions in direct ophthalmoscopy, 


media are clear, he should by proper focusing be able to find the arteries, 
veins, macula, and optic disc. If the surgeon has an error of refraction 
he should wear his correcting lenses; the patient’s error can be corrected 
by means of a lens placed behind the ophthalmoscope. Both the patient 
and the surgeon should keep both eyes open. The patient should not look 
directly into the mirror, since this will cause the pupil to contract, in case 
a mydriatic has not been used. The surgeon should learn to lay aside his 
accommodation, and this is an art that comes only with practice. The tyro 
will look at the fundus as at an object very close, while the experienced 
ophthalmoscopist will view it as if it were far distant. The patient’s 
accommodation should be kept in abeyance either by the use of a cycloplegic 
or by gazing at a distant object. 

In using the indirect method, the surgeon is to hold the mirror with 
the right hand at 50 centimetres from the patient’s right eye, while the 
strong convex lens is placed in his left hand (Fig. 123). When the left 








EXAMINATION OF THE EYE. 


139 


e}’e is being looked at, the surgeon should use his left eye and left hand. 
To see the head of the nerve the patient should turn the eye slightly toward 
his nose. The macula can be brought into view by having the patient look 
directly at the mirror. The peripheral parts of the retina can be examined 
by rotating the eye peripherally. If the view of the fundus is not clear, 
it can be made so by the use of a strong convex lens. Reflexes from the 
cornea and lens are often complained of by the examiner. They can be 
eliminated by tilting the mirror, by changing the position of the lens, or 
by altering the situation of the light. 

The Size of the Ophthalmoscopic Image varies with the conditions 
under which the methods are employed, and with the refraction of the two 
eyes. The magnification of the details of an emmetropic eye examined by 
direct ophthalmoscopy is about seventeen times that of normal. In hyper- 
metropia it is less; in myopia it is greater. A plane mirror gives a larger, 
but less brightly illuminated, image than the concave one. 



Uses of the Ophthalmoscope. —The ophthalmoscope is used: (1) 
tc detect opacities in the dioptric media, (2) to study the fundus, (3) to 
determine the refraction, and (4) to demonstrate differences of level in the 
fundus. 

To Detect Opacities the concave mirror of the ophthalmoscope is used. 
The opacity appears as a dark cloud or black spot on the red background. 
Any spot appearing black by this method of examination looks white or 
gray by oblique illumination, for this reason: rays of light from the fundus, 
falling on an opacity from behind, are returned unseen by the surgeon; 
and, in oblique illumination, rays of light striking an opacity from in front 
do not reach the retina, but are reflected into the eye of the examiner. 
To locate an opacity it should be remembered that opacities in the cornea 
and lens are immovable, while vitreous opacities are generally floating, but 
in rare instances may be fixed. Hence, after moving the eye, vitreous opaci¬ 
ties float, while corneal and lenticular ones are stationary. In many cases 
an opacity can be localized by oblique illumination. To distinguish between 



140 


MODERN OPHTHALMOLOGY. 


% 

an opacity in the cornea, and one in the anterior or posterior part of the 
lens, it is often necessary to nse parallactic displacement. This can be 
understood by reference to Fig. 124, in which the points, a■, b, and c repre¬ 
sent, respectively, opacities in the cornea, anterior and posterior parts of 
the lens. If the surgeon looks at the eye in the direction of the optic axis, 
he sees only one opacity, as shown in the upper figure. If, however, the 
patient looks downward, all of the opacities are seen, that of the posterior 
part of the lens being highest, that of the anterior part of the lens in the 
middle, and the corneal opacity lowest. An apparent movement upward 
when the eye is actually turned downward proves that the opacity is behind 
the plane of the iris; an apparent movement in the same direction as the 
actual movement of the eye shows the opacity to be located in front of the 
plane of the pupil. If the patient’s eye is held still and the surgeon moves, 
the opposite is true, opacities in front of the pupil seemingly moving in 



the opposite direction, while those behind the iris move in the same direc¬ 
tion. Finally, any opacity which is found is to be inspected at close range 
by using a strong convex lens behind the ophthalmoscope. Besides its use 
in finding opacities, the ophthalmoscope, used as described above, readily 
detects a tear in the iris or the existence of a partial dislocation of the lens. 

Examination of the Fundus .—The media being clear, the surgeon pro¬ 
ceeds to examine the fundus, a description of which is' found in Chapter II. 
It will be well to use the indirect method first, thus gaining a general idea 
of the state of the eye. The surgeon sits about 40 centimetres from the 
patient, illuminates the pupil with light reflected from the mirror, inter¬ 
poses the convex glass in the path of luminous rays, and searches for the 
head of the optic nerve. The lens must be held squarely in front of the 
eye, otherwise the fundus will appear distorted. To find the optic disc, 
in examining the right eye, the patient should look in the direction of the 






EXAMINATION OF THE EYE. 


141 


surgeon's right ear. After studying the disc for pathologic changes the 
vessels, the macula, and the peripheral parts of the retina are passed in 
review. The fundus is next to be examined minutely by the direct method. 
Inability to see the details of the fundus clearly will suggest the presence 
of an error of refraction too great for the accommodation to overcome. 

The Ophthalmoscope as a Rcfractometcr .—Used as a refractometer, 
the ophthalmoscope is employed for two purposes: to determine the nature 
of an error of refraction and its amount. The former is accomplished by 
holding the mirror at from 30 to 50 centimetres from the eye to be exam¬ 
ined. The surgeon illuminates the eye, looks through the mirror, and seeks 
for vessels. If any are seen, the eye is ametropic. To determine the nature 
of the error the surgeon has only to move his head from side to side and 
watch the movement of the vessels. If they move apparently in the same 
direction as the surgeon’s movement, the eye is hypermetropic; if Opposite, 
it is hypometropic (myopic). 

In the hands of experts the ophthalmoscope can be used to determine 
the amount of refraction errors. Either the direct or indirect method may 
be employed, although the former is preferred as the simpler procedure. 
In the remarks to follow reference will be made alone to the direct method. 
In order to measure refraction with the ophthalmoscope, several conditions 
must be complied with:— 

1. The accommodation of both patient and surgeon must be relaxed. 

2. A particular part of the fundus must be selected to be refracted. 

3. The surgeon must be emmetropic; if ametropic, his error must be 
corrected. 

4. The surgeon should approach as closely as possible to the eye to 
be refracted. 

5. The findings of the ophthalmoscope must be confirmed by other 
tests before the surgeon prescribes for the patient. 

In explanation of these rules it is necessary to state that the accom¬ 
modation of the patient is usually relaxed by the use of a cycloplegic or 
by having him look at a distant object, while the art of holding his own 
accommodation in abeyance comes to the surgeon after long practice. In 
selecting a part of the fundus to be refracted, it is customary to choose 
either the optic disc or, preferably, one of the vessels at the temporal side 
of the disc near the macula. The surgeon should approach a point 13 
millimetres in front of the cornea, this being the anterior focal point of 
the eye. If a greater distance is chosen, it will be necessary to subtract the 
distance from the glass to the cornea from the lens selected to correct hyper- 
metropia, and add it to the correction for hypometropia (myopia). 

In case an emmetropic eye examines another eye which is emmetropic, 
the image will appear clear and distinct, because rays coming from the 
normal eye are parallel. In Fig. 125 the examiner, E, looks into the 
emmetropic eye of the patient, T ; and a clear image of St will be formed 
at Mo on the retina of the examiner. If, however, the surgeon does not 


142 


MODERN OPHTHALMOLOGY. 


obtain a clear image of the fundus, it will be in order for him to place a 
convex glass behind the mirror. 

If this improves the picture of the fundus, the surgeon increases the 
strength of the glass until he obtains the strongest convex lens through 
which the details of the fundus can be obtained. This glass is the measure 
of the patient’s hypermetropia. Ophthalmoscopy rmder these conditions 
is explained by Fig. 126, in which rays coming from the retina of the 
hypermetropic eye, II, appear as if coming from a more remote point, I, 



Fig. 125.—Ophthalmoscopy in emmetropia. 

The eye of the examiner, E, and of the patient, T, are normal in refraction. 


behind the eye. The convex lens renders the divergent rays parallel, and 
they are brought to a focus at C on the retina of the examiner. 

If the surgeon finds that his view of the fundus is made more dim by 
the convex glass, he should move the disc and place a concave lens behind 
the mirror. The weakest concave glass with which the details of the fundus 
can be recognized is the measure of the patient’s hypometropia (myopia). 
Possibly the surgeon will be able still to see the fundus through a glass 1 
or 2 D. stronger; but he does so only by calling his accommodation into 



Fig. 126.—Measurement of hypermetropia by direct ophthalmoscopy. 


play. Rays emerging from the myopic eye are so convergent that they 
would meet at the punctum remotum, C (Fig. 127). The concave lens 
renders them parallel, and they fall on the emmetropic eye of the surgeon 
to form a focus at s. 

The application of ophthalmoscopy to astigmatism comprises, first, 
the diagnosis of astigmatism, and, second, its measurement. For these 
purposes the direct method is preferred. If the surgeon examines an astig¬ 
matic eye, he will observe that the picture is blurred in parts; when vessels 
running vertically are in focus, those taking a horizontal course are blurred, 










EXAMINATION OF THE EYE. 


143 


and vice versa. Much stress is laid upon the shape of the optic disc as 
characteristic of astigmatism, the round disc of the normal eye being seen 
apparently oval in astigmatism. It is unwise, however, to depend on this. 
A better criterion is that afforded by the ability of the surgeon to see all 
parts of the disc clearly at the same time. In astigmatism this will be 
impossible; when the temporal and nasal sides of the disc are clear, the 
upper and lower borders are out of focus in the astigmatic eye. The differ¬ 
ences produced in the retinal picture by irregularity of curvature of the 
lens or cornea will enable the surgeon to measure the defect by direct use 
of the ophthalmoscope. The retinal vessels are taken as the objective points 
in the examination. It is to be remembered that horizontal lines or vessels 
are seen through the vertical meridian of the cornea and vertical lines or 
vessels are seen through the horizontal meridian. Kemembrance of this 
simplifies the problem which, in truth, is the measurement of the hyper- 
metropia or hypometropia (myopia) of each of the principal meridians, 
the difference between these findings constituting the astigmatism. If, 
for example, the surgeon sees the vertical vessels clearly with a weak concave 
lens (2 D.) and the horizontal vessels are clear only after the interposition 



c 


T 


s 


Fig. 127.—Measurement of hypometropia (myopia) by direct 

ophthalmoscopy. 


of a convex glass of 4 D., it follows that the case is one of mixed astig¬ 
matism (myopia of 2 D. in the horizontal and hypermetropia of 4 D. in 
the vertical meridian). If the horizontal vessels are clear without any 
glass, and the vertical ones are seen best with a convex ID., there is simple 
hypermetropic astigmatism of 1 D. Should the vessels in one principal 
meridian be clear only with a-f 2D. lens and those in the other principal 
meridian require a -j- 3 D. glass, the case is one of compound hypermetropic 
astigmatism. In the estimation of refraction by ophthalmoscopy the meas¬ 
ure of error is the weakest concave lens and the strongest convex one which 
renders the vessels clear. 

In conclusion it must be said that the estimation of refraction by the 
ophthalmoscope is unreliable, except in the hands of a few experts, and that 
in all cases the findings by this method should be confirmed by retinoscopy, 
keratometry, and the use of the trial-case. 

The Deterinination of Differences of Level in the Fundus, which is of 
practical value in the swelling of the nerve-head occurring in optic neuritis 
and its excavation in glaucoma, may be accomplished in one of two ways: 
by the phenomenon of parallax or by the measurement of the refraction of 








144 


MODERN OPHTHALMOLOGY. 


two points occupying different elevations. Parallactic displacement is pro¬ 
duced by moving the convex lens in indirect ophthalmoscopy. By shifting 
the lens it is noticed that two observed parts of the fundus image move at 
unequal rates in case a difference of level exists. Thus, in a glaucomatous 
excavation, the vessels climbing over the edge of the optic disc will move 
faster and in front of those in the bottom of the cup. In case a projection 
of the nerve-head occurs, as in papillitis and in intra-ocular tumor, the 
same phenomenon will be observed. Appreciation of parallactic displace¬ 
ment may be facilitated by study of Fig. 128. Here a glaucomatous ex¬ 
cavation of the nerve-head reaches from o to s. When the convex glass 
is placed at B, the points o and s are in line, and the idea of depth does 
not obtain, since one point covers the other. If, however, the lens is dis¬ 
placed to C , it will be observed that the image of the point o is reproduced 
at oo and that of s is likewise reproduced at ss; and the points seem 
to have separated, o moving more rapidly than s. 





oo 

Fig. 128.—Diagram to show parallactic displacement in 
indirect ophthalmoscopy. 


In order to measure elevations and depressions of the fundus by oph¬ 
thalmoscopy it is necessary to proceed as in the measurement of errors of 
refraction: the glass is found which brings the depth of an excavation into 
focus and then it is ascertained what glass will clear the image of the parts 
normally situated. The difference expressed in dioptres and multiplied by 
0.3 will give the depth of the excavation in millimetres. For example, let 
it be supposed that, in a case of glaucomatous cupping, the depth of the 
excavation is in focus with a — 5 D. glass, and the margin of the disc 
and adjacent retina are best seen with 1 D., a difference of 6 D. The 
depth of the excavation is 1.8 millimetres. In the same manner a swelling 
of the nerve-head can be measured. 

The Fundus Reflex Test. —If light be thrown into the eye by a mirror, 
and the mirror be slightly tilted while the surgeon is looking through it, 
a shadow will be seen passing across the pupillary area. The direction and 




EXAMINATION OF THE EYE. 


145 


rapidity of movement of the shadow are indicative of the kind of refraction 
error and its amount. A rapidly moving shadow means a small error; a 
slowly moving one means a considerable or large degree of ametropia. The 
direction in which the shadow moves tells the skilled observer the kind of 
error; and the direction of movement depends on whether a concave or a 
plane mirror is employed. Eetinoscopy (skiascopy, the shadow test, koros- 
eopy, keratoscopy, pupilloscopy) is the determination of the refraction by 
the observation of the shadow which results from reflecting light into the 
eye by a mirror. In describing this test ophthalmic writers use the terms 
“area of light,” “the illuminated area,” and “the illumination” synony¬ 
mously; while the terms “shadow” or “shade” mean practically the same 
thing, since the “shadow” is simply the place where the illuminated area 
ceases and darkness begins. It is not meant that the shadow of any object 
is thrown on to the retina. 

In practical value this test is not surpassed by any. Being an objective 
test, it is of the greatest importance in the young, the deaf and dumb, the 
illiterate, among malingerers and plaintiffs seeking damages, and in all other 



F 

Fig. 129.—Diagram to explain retinoscopy with the concave 
mirror. (After Landolt.) 


cases of refraction error. By its use not only can myopia and hypermetropia 
be measured accurately, but it also enables the surgeon to measure .the 
amount of astigmatism and determine the direction of the principal merid¬ 
ians. 

The principle of retinoscopy is the finding of the point of reversal, or 
far point, of a myopic eye. When the myopic eye is examined by direct 
ophthalmoscopy an erect image is seen; at some distance from the eye an 
inverted aerial image appears, which is formed at the conjugate focus, or 
far point, of the eye. It is here that the erect changes into the inverted 
image. Eetinoscopy is a method of determining this point of reversal. 
Emmetropic and hypermetropic eyes are to be given an artificial myopic 
far point by the addition of a convex spheric lens. 

The changes occurring in an eye examined with the concave mirror have 
been explained by Landolt. 

In Fig. 129 the surgeon, 0, examines the eye of the patient, P, by 
the concave mirror, M, the source of illumination being at F. The mirror 


10 



146 


MODERN OPHTHALMOLOGY. 


produces a real inverted image of the flame at ff, which becomes the actual 
source of illumination. The observed eye receives a retinal image, s, of ff, 
and, regardless of its refractive condition, the image is inverted relatively 
to the object. The image will be more or less distinct according to the 
refraction. If the image is inverted its movements also are inverted rela¬ 
tively to those made by the object. If the mirror is rotated from right to 
left, the real image, ff, passes from right to left also, while the retinal 
image, s, moves from left to right. It can be easily demonstrated that, 
regardless of the refraction of the examined eye, the image of the flame 
which illuminates the fundus always moves opposite to the motion of the 
concave mirror. 

However, the illuminated part of the fundus becomes the object for 
the surgeon’s eye; and this fact, subject to the law of conjugate foci that 
the image can replace the object and the object take the place of the image, 
lies at the basis of retinoscopy, for the retina and far point of the eye are 
conjugate foci, images being formed at either according to the refraction 
of the eye examined. If the eye is myopic 1 D., its far point is at 1 metre, 
and this is the point of reversal. If the eye of the patient is emmetropic 
or hypermetropic, rays coming from it are not brought to a focus, unless 
on the retina of the surgeon’s eye. Hence, the surgeon sees the fundus in 
the erect image, and the ocular luster moves in the same direction with the 
image of the flame at the fundus of the eye, P: i.e., opposite the movement 
of the mirror. With the myopic eye, however, the case is different. Let 
us suppose that P is a myopic eye whose far point is in the plane of R. 
When such an eye is examined with the concave mirror, an inverted image 
of s appears at R, the inversion being produced by the dioptric media of 
the eye. R, therefore, has the same direction as ff, and, of course, undergoes 
the same movements. If ff moves with the mirror from right to left, and s 
from left to right, then R moves from right to left. It is evident that s is 
simply the illuminated part of the fundus which the surgeon observes in 
the patient’s pupil. The pupil is seen in its real position, while the fundus 
appears inverted. If the mirror which illuminates the eye passes from 
right to left, the pupil is lighted up likewise from right to left, although, 
in reality, the light passes from left to right at the fundus of the examined 
eye. Hence in myopia the shadow moves in the same direction as the 
concave mirror. This, however, is true only when the surgeon is at a certain 
distance. If the surgeon approaches P closely enough to intercept rays 
before they reach their focus, as occurs when 0 is between R and P, the 
inverted image is not formed in the air in front of the surgeon, but only 
in his eye, as in emmetropia or hypermetropia. In this case the shadow 
would move the same in myopia as in emmetropia and hypermetropia. Con¬ 
sequently the refractive condition cannot be diagnosed at the first glance 
by retinoscopy. If the surgeon is 1 metre from P, the inverted image 
cannot be seen unless the myopia of P is more than 1 D. If the surgeon 
is slightly more than 1 metre from P and the examined eye shows a general 


EXAMINATION OF THE EYE. 


147 


illumination without any movement of a shadow, we know there is myopia 
of 1 D. If the shadow moves rapidly against the mirror when P is exam¬ 
ined, and after adding a -f- 1 D. lens the shadow does not move, but the 
whole pupil is brilliant, we have to deal with emmetropia. If a convex 4 
D. lens is needed to produce such a result, we know the amount of hyper- 
metropia is 4 D. — 1 D. = 3 D. If a concave 4 D. lens is required, the 
amount of myopia is 4 D. -f- 1 D. = 5 D. 

Thus we have seen what is the real movement of the light on the fundus, 
and this can be demonstrated in an enucleated eye; however, it is not this, 
but the apparent movement with which the surgeon is concerned. With 
the concave mirror the apparent movement in the pupil is the same as the 
real movement in the fundus in emmetropia, low myopia, and hyper- 
metropia. In myopia of more than 1 D. it is the opposite: i.e., with the 
mirror. 



Fig. 130.—Retinoscopy mirror. 


In using this test the surgeon should wear his correcting glasses, if he 
be ametropic. He need not give attention to his accommodation, but should 
keep both eyes open and observe closely the movement of the shadow. The 
patient’s accommodation, however, must be eliminated by means of a reliable 
cycloplegic. To refract the macula, the patient should look at the sight- 
hole of the mirror. The instruments needed for retinoscopy are a concave 
mirror of 2 centimetres’ diameter and 25 centimetres’ focus,' with a circular 
central perforation 2 millimetres in diameter; a movable gas-bracket with 
an Argand burner; an asbestos chimney with iris-diaphragm (Fig. 131); 
a trial-frame and box of trial-lenses; and a room that is perfectly dark. 
The remarks to follow concern retinoscopy with the concave mirror. 

The light is to be placed above and behind the patient’s head, the sur¬ 
geon sitting 1 metre from and directly in front of the patient. Light from 





































148 


MODERN OPHTHALMOLOGY. 


the mirror is to be thrown on to the eye to be examined. The surgeon, 
looking through the mirror, moves it slightly in a- vertical, then in a hori¬ 
zontal, direction, and notes the movement of the shadow. With the concave 
mirror the shadow moves with the mirror in myopia greater than 1 D., and 
against the mirror in emmetropia, hypermetropia, or low myopia. Let us 



suppose that the shadow moves slowly against the mirror. This means that 
the case is one of hypermetropia of considerable amount. The trial-frame 
is adjusted and the eye not under examination is covered with an obturator. 
The patient is told to look at the surgeon's forehead; a convex glass (+4 


Fig. 132.—Movement of the shadow in myopia. 


Tlie concave mirror is used. The arrow at the right shows the direction in which the 
mirror is moved, and the white arrow marks the direction of movement of the shadow. 
The shadow moves with the mirror. 


D.) is placed in the trial-frame and the shadow is now found to move more 
rapidly against the mirror. This means that part of the hypermetropia has 
been corrected. A stronger convex glass (-f- 5 D.) is added, which gives 
not only no motion against, but a slight movement with the mirror. This 
glass is the measure of the hypermetropia plus the algebraic quantity — 1 































EXAMINATION OF THE EYE. 


149 


D., which must be added because the surgeon is distant 1 metre. Hence, 
the true amount of hypermetropia in this case is (-f 5 D. — 1 D. = -f- 4 
D.) 4 D. If the surgeon sits 2 metres distant, the algebraic quantity — 0.50 
D. must be added to the glass which causes a reversal of the shadow. In 
using the shadow test the refraction of the vertical meridian is determined 
by moving the mirror on its horizontal axis; and the horizontal meridian 
is measured while tilting the mirror on its vertical axis. 

Let us take another case: the shadow moves slowly with the mirror. 
This means myopia, and to measure it the surgeon places concave glasses 
of increasing strength in the trial-frame until the shadow moves slightly 
against the mirror. This glass, plus the algebraic quantity — 1 D., is the 
measure of the myopia. 

In astigmatism the pupillary area is occupied by a band of light which, 
as a rule, runs either vertically or horizontally, but may occupy an oblique 
meridian. Whatever the direction of the band, it indicates accurately the 
axis of one of the principal meridians. The band of light can usually be 



Fig. 133.—Movement of the shadow in emmetropia, low 
myopia, and hypermetropia. 

The concave mirror is used. The arrow at the right shows the direction in which the 
mirror is moved, and the white arrow marks the direction of movement of the shadow. 
The shadow moves against the mirror. 


seen before a correcting sphere is placed before the eye; but in low degrees 
of astigmatism the band is noticed only after the proper spheric correction 
of the myopia or hypermetropia has been made. The problem of measuring 
astigmatism by skiascopy simply resolves itself into the measurement of the 
meridian of greatest and that of least refraction, correcting each by the 
proper sphere. The difference between these findings is the amount of 
astigmatism. It must be remembered, however, that the edges of the band 
of light are at right angles to the meridian tested. Thus, in Fig. 135, the 
diagram at the left (1) shows an astigmatism which is to be corrected by a 
cylindric lens at 90°, the meridian tested being horizontal, Tj and the 
figure at the right (2) shows a similar condition, the axis here being at 
180° and the meridian tested being vertical, To. As an example of the 
correction of astigmatism by retinoscopy let us suppose that Fig. 134 
represents an eye in which the vertical meridian is neutralized by a 
-|- 4 D. lens and the horizontal meridian requires — 4 D. Here is an 







150 


MODERN OPHTHALMOLOGY. 


instance of mixed astigmatism, and the refraction is expressed in this way: 

r aa 

-“J o0 following the rule that the algebraic quantity— 1 D. must be 

added to the lens causing reversal of the shadow. The correcting glass in 
this case can be written in three ways: 1. —5.00 cylinder (axis, 180°), 
combined with (3) + 2.00 cylinder (axis, 90°). 2. —5.00 spheric 3 + 

8.00 cylinder (axis, 90°). 3. +3.00 spheric C —8.00 cylinder (axis, 

180°). The third way is used by most opticians, who prefer working minus 
cylinders on to plus spheres. 

The obtaining of the exact axis in astigmatism is much facilitated by 
retinoscopy. For this purpose a meridian indicator, called an axonometer 
(Fig. 136), can be placed in the trial-frame and rotated until the white 
lines on either side of the central opening coincide with the long axis of 
the band of light seen in the pupil. The degree on the rim of the trial- 
frame, to which the axonometer points, is the axis at which the cylinder is 
to be placed. 



Fig. 134.—Movement of the shadow in mixed astigmatism. 

The direction of the (concave) mirror movement is indicated by the black arrow ; the white 
arrow shows the direction in which the shadow moves. 


The overcorrection of retinoscopy depends on the distance between the 
surgeon and the patient. When this is 1 metre the overcorrection equals 
the focal length of a 1 D. glass; if at 2 metres, 0.50 D.; and at 4 metres, 
0.25 D. Most ophthalmologists use retinoscopy at 1 metre; some, however, 
hold that the detection of a low degree of astigmatism becomes easier at 2 
metres. This amount is to be subtracted from the skiascopic correction, 
thus giving the actual amount of refraction-error. This finding, however, 
is not the measure of the glass to be prescribed, since ophthalmic surgeons 
find that it is inadvisable to prescribe the full correction of an error. The 
amount of reduction will be fully discussed in the chapter on refraction. 
In any case the retinoscopic findings should be confirmed by the use of the 
trial-case and the ophthalmometer. 

Retinoscopy 'with the Plane Mirror. —With the plane mirror it 
is necessary to have the source of illumination close to the mirror. The 





EXAMINATION OF THE EYE. 


151 


movement of the shadow with the plane mirror is the reverse of what 
obtains when the concave one is used, viz.: with the plane mirror the 
shadow moves with the mirror in emmetropia, hypermetropia, and low 
myopia. The retinoscopic examination is much facilitated by the use of 
one of the several skiascopes which are on the market. These are instru¬ 
ments holding lenses and permitting the rapid change of the lens-strength. 
Some of them are to be held by the patient, while others are turned by the 


90. To 



Fig. 135.—Diagram to show correction of astigmatism. 

surgeon. Among the hand-skiascopes are those of Snell, Gruening, and 
Marple; revolving skiascopes have been invented by Jennings, Lambert, 
and others. 

Tests for Simulated Blindness.—The tests for simulated blindness are 
the obstruction device, various tests with prisms and lenses, the mirror test, 
the stereoscopic test, Snellen’s colored letters, and Hering’s experiment with 


Fig. 136.—Thorington’s axonometer. 

falling bodies. These tests apply to simulation of blindness in one eye. If 
the patient claims blindness in both eyes only careful watching will expose 
the deception. 

The Obstruction Device can be employed by holding a ruler on the 
flat in front of a book from which the patient reads. If binocular vision 
exists, he will see all the words and will read without halting; if one eye 
is blind, certain words will be hidden by the ruler. 













152 


MODERN OPHTHALMOLOGY. 


Tests with Prisms are numerous. The following may be used: 1. 

Place a 7° or 8° prism, base up or down, in front of one eye and direct 
the patient to look at a candle at 6 metres. If he sees double, binocular 
vision is present, and he is shamming. 2. Place in front of each eye a 7° 
prism, base out, and ask the patient to look at a flame at 6 metres; if 
binocular vision exists there will be a noticeable convergence of the visual 
axes. 3. Hold a 12° prism, base out, before the blind eye. If the eye sees 
there will be a movement of it inward to overcome crossed diplopia. 4. 
Place a square prism with its edge half-covering the pupil of the good eye, 
the supposedly blind one being covered. Monocular diplopia is thus pro¬ 
duced. Now move the prism entirely over the good eye and at the same time 
uncover the other; if diplopia still exists, the patient is malingering. 5. 
Place a prism, base vertical, in front of either eye and direct the patient 
to walk downstairs. If he closes one eye binocular vision is present. 6. 
Place a piece of Iceland spar in front of one eye. If three images are 
present, binocular vision exists. 7. Place a Maddox double prism accurately 
before one eye, the other being uncovered. The presence of three images 
proves binocular vision. 8. Place a -f- 14 D. glass before the sound eye and 
a — 0.25 s before the other and ask the patient to read test-types at 6 metres. 
If he reads, it is with the eye which he claimed was useless—barring, of 
course, aphakia. 9. Place the Maddox rod before the good eye. If the 
patient sees both the flame and the light-streak, he is shamming. 10. Use 
Snellen’s spectacles and red-green test-letters. The spectacles have one red 
and one green glass. The patient is to read the transparent red and green 
letters, which are hung up in a window. It is best to have him read the 
letters first without the spectacles. Then the spectacle-frame is adjusted, 
both eyes being kept open, and the letters are to be read. If the patient 
does this, binocular vision is present. The green glass excludes all the rays 
from the red letters and likewise the red glass excludes rays from the green 
letters. Hence some letters are seen only with one eye, and others with the 
other. 

Hering’s Experiment with falling bodies can be used as a test for 
malingering. The patient looks with one eye through a long tube at a 
thread stretched vertically. Glass beads are then dropped in front of and 
behind the thread. If binocular vision is present the patient will correctly 
state whether the beads were in front of or behind the thread; if blind 
in one eye he will make numerous mistakes. 

Stereoscopic Tests are numerous. One of the simplest is to use the 
letters L and E, which, to the person with binocular vision, make E. If 
the patient says he sees E, he is using both eyes. 

Fridenberg’s Mirror Test is of great value. It consists in the use 
of an instrument carrying a mirror and two test-cards, and is described 
as follows: “The mirror is mounted on a horizontal arm in such a way as 
to permit of varying its distance from the test-card, and of presenting it 
alternately to either eye by revolving the bearing through an arc of 180°. 


EXAMINATION OF THE EYE. 


153 


The lateral tilt of the mirror can be changed at will, and is indicated by a 
pointer on a horizontal scale. When the pointer is at 90°, the plane of 
the mirror is at right angles to the line of vision of the eye on the corre¬ 
sponding side, and this eye sees its own image. The test-card on this side, 
however, is not normal to the mirror, and its reflection is' seen only by the 
opposite eye, which the subject presumes to be unconcerned in the visual 
act, as it does not appear in the mirror. 

“A slight tilting of the mirror to the temporal side, bringing the pointer 
to 95° or 100°, is sufficient to reverse the optical conditions, so that the test 
is seen only by the eye on the same side. By switching the mirror over to 
the opposite side of the arm, a similar double test can be applied, so that, 
in all, eight variations are rapidly obtained, as follows:— 



Fig. 137.— Test for simulated blindness. (Fridenberg.) 


Mirror before Eight Eye. 
95° R. E. sees right card. 
90° L. E. sees right card. 
70° R. E. sees left card. 
60° L. E. sees left card. 


Mirror before Left Eye 
95° L. E. sees left card. 
90° R. E. sees left card. 
70° L. E. sees right card. 
60° R. E. sees right card.” 


Localization of Foreign Bodies.—Occasionally a foreign body can be 
seen by oblique illumination or by ophthalmoscopy. In most cases, how¬ 
ever, it is out of view either because of its position, the presence of blood, 
distortion of tissues, or inflammatory changes. In such cases attempts were 
formerly made to locate it, if of iron or steel, by the movement of magnetic 
needles arranged in the sideroscope of Asmus or of Hirschberg. The at¬ 
tempt has been made to accomplish the same result by bringing strong 
magnets in close proximity to the eye, expecting the movement of the for¬ 
eign body to produce pain, and thus assist in the localization, which may 
be the case if the foreign body is jagged in outline and situated in the 
ciliary region. This method has been superseded by the use of the x-rays. 
Non-metallic, as well as metallic, particles can be located in almost all 
















154 


MODERN OPHTHALMOLOGY. 


cases. The methods of greatest value in localization by the x-rays are those 
of Leonard, Sweet, and Davidson. All are founded on triangulation. 

Leonard’s Method. —Leonard, who was a pioneer in the use of the 
x-ray in ophthalmic surgery, devised a method of localization in which the 
base-line for triangulation is made anterior to the cranial shadow. The 
exposures are to be repeated at fixed distances and set situations, giving a 
series of relational sides and angles from which the surgeon calculates the 
position of the foreign body. 

Sweet’s Method. —Sweet fixes to the side of the patient’s head a plate¬ 
holding device, which carries two steel rods, each bearing a ball at its end. 
These ball-pointed rods are at all times parallel to each other and with the 
photographic plate, and are at a known distance apart. One rod points 
to the centre of the cornea, the other to the outer canthus, both being parallel 
to the visual line and perpendicular to the plate. Two radiographs are 
made, one with a tube parallel, or nearly so, with the plane of the two rods, 
and the other above or below this, the first situation. From a study of the 
shadows cast by these ball-pointed rods in relation to the shadow of the 
foreign body, the surgeon is able, on a horizontal and vertical diagram¬ 
matic section of the eyeball, to locate the position of the foreign body. 
This is achieved by taking the distance that the shadow of the foreign body 
is above or below the shadow of the indicating balls on the two negatives, 
and transferring these measurements above or below the spots representing 
the two indicator balls on the vertical section of the eyeball. A line drawn 
through these points gives the plane of shadow of the foreign body at the 
two exposures, their crossing point indicating the situation of the metal in 
the eye as studied in relationship to the centre of the cornea. 

In determining the position of the body when back of the centre of 
the cornea, the distance is measured so that the shadow of the body is poste¬ 
rior to the shadows of each of the two balls on the plate made with the tube 
horizontal to the plane of the indicators. These measurements are entered 
above the spots representing the two balls on the diagram of the horizontal 
section of the eyeball, and a line is drawn through these points which indi¬ 
cates the plane of shadow of the foreign body. A line is now drawn per¬ 
pendicular to the situation of the body as found on the vertical section of 
the ball. Where it crosses the line representing the plane of shadow on the 
horizontal section is the situation of the body back of the anterior portion 
of the cornea. 

Davidson’s Method. —Mr. McKenzie Davidson uses a Crookes tube 
whose anode is made of osmium (so as to obtain the best definition) placed 
between two pieces of platinum, a head-clamp, and a localizer. Two scia¬ 
graphs are taken from different points of view. First, a piece of lead wire, 
1 centimetre long, is plastered on to the patient’s eyelid, forming a fixed 
point in the picture to be taken. The position of the tube can be moved 
by means of a crossbar. The side of the head with the injured eye being 
fixed flatly against two piano wires stretched across a space in a board 


EXAMINATION OF THE EYE. 


155 


admitting a photographic plate, as shown in Fig. 138, the first picture is 
taken; then the bar is moved 6 centimetres and the second picture is made. 
The patient meanwhile looks at a point directly in front, so situated that 
the visual axis of the injured eye is parallel to the horizontal wire. On 
the negative are seen the images of two wires which cross at right angles. 
They are stretched across the window in which the photographic plate is 
fastened. The two negatives are fixed and each one shows the lead wire 
and the foreign body. After developing the negatives, a tracing in celluloid 
is made of each, showing the crosswires and any foreign body present. By 



Fig. 138.—Apparatus for fixing the head in x-ray examination. 

(Davidson.) 

mathematical calculations it would be a tedious task to locate the foreign 
body; hence Mr. Davidson has designed his localizer, which consists of a 
stand with a plate-glass top under which is a mirror for throwing light 
from below upward. A horizontal bar, on which is a millimetre scale, pro¬ 
jects from the top of the table. On the glass plate are two lines cut at 
right angles, corresponding to the two crosswires shown on the negative. 
The sliding millimetre scale is placed above the glass plate a distance equal 
to the distance of the anode of the Crookes tube from the negative at the 
time the picture was being taken. At the time of the exposure the surgeon 
should mark on the patient’s skin the quadrant which corresponds to the 







156 


MODERN OPHTHALMOLOGY. 


lead wire. (The crosswires have previously been brushed over with ink or 
a suitable dye and the patient’s head, resting on the wire, is marked into 
quadrants by the dye.) 

The negative is now placed on the localizer. Since the x-ray is not 
bent, but passes straight through an object, it is possible to represent the 
path of the ray by threads stretched from the scale to the image of the 
foreign body on the negative. This is shown in Fig. 139. The further 
procedure is thus described by Mr. Treacher Collins:— 

“The negative with the two images of the foreign body and of the 
pointing lead wire, when developed, is placed on the stage of an instru¬ 
ment called The crossthread localizer.’ It resembles a photographer’s re- 

8 § 


Fig. 139.—The crossthread localizer. ( Davidson.) 

touching desk. Upon an iron stand a piece of plate glass is placed hori¬ 
zontally and level. Below this is a mirror, which can be adjusted so as 
to reflect upward the light from a window or lamp. Above the plate-glass 
stage is a horizontal bar with a millimetre scale which slides up and down 
upon two vertical brass rods. The plate-glass stage has two lines cut at 
right angles to each other on it; when the instrument is in use the hori¬ 
zontal bar is made to bear the same relation to these cut lines as the hori¬ 
zontal bar, along which the Crookes tube moved, did to the crosswires. 

“When the negative is laid on the stage, the white cross on it produced 
by the wire is made to lie on the cut lines; so that it is placed in relation 
to the horizontal bar under exactly the same conditions as it occupied when 
it was being taken. 






































EXAMINATION OF THE EYE. 


157 


“The path of the x-rays during the two exposures is traced by means 
of threads, which are separated on the horizontal bar the same distance as 
that which separated the position of the tube during the two exposures. 

“Small lead weights with needles attached, through the eyes of which 
the threads are secured, are used to keep the threads taut, and direct them 
to the exact points on the negative required. 

“If the two threads are arranged to start from the horizontal bar in the 
positions in which the tube was during the two exposures, and the point of 
each needle carrying the thread is placed on a corresponding point of the 
image produced by each exposure, then the position where the threads cross 
will correspond to that occupied by that point of the foreign body in relation 
to the plane of the plate. The distance is next measured from the two 
vertical planes represented by the shadows of the crosswires. This is done 
by the use of an upright square placed with its edge coincided with the 
edge of the shadow, first on one side of the foreign body and then on the 
one at right angles. The relation of the pointing lead wire is also estimated 
to these planes and to the foreign body, and with these data the exact 
position of the foreign body in a schematic eve is easily worked out.” 

The Siderophone. —Jansson has invented an instrument for the 
detection of pieces of iron or steel within the eye. It consists of an electro¬ 
magnet to which a telephone is attached. When brought near a piece of 
iron a change is produced in the electric current, and this produces a sound 
in the telephone which can be easily heard. 


CHAPTER V. 


DISEASES OF THE EYELIDS. 

The eyelids are subject to congenital anomalies, tumors, traumatisms, 
inflammations, parasites, degenerations, infiltrations, etc. Owing to the 
complexity of the structures entering into their formation, the lids show 
many symptoms pertaining to general diseases. The diseases of the con¬ 
junctiva are of such importance as to demand consideration in a separate 
chapter. 


CONGENITAL ANOMALIES OF THE EYELIDS. 

These defects are rarely met with. The following conditions have been 
found:—■ 

Ablepharia.—Partial or complete absence of the lids may occur on 
one or both sides, and is a rare defect. 

Coloboma of the Lids generally is present as a triangular defect with 
the base toward the lid-margin and the apex directed toward the margin 
of the orbit. It is more frequent in the upper lid. Cases in which the 
coloboma is situated at the inner or outer canthus are extremely rare. The 
defect commonly involves the entire thickness of the lid, and in extent 
varies from a mere notch to a deep fissure. In the colobomatous area 
Meibomian glands and cilia are absent. In some instances the defect is 
filled by a bridge of tissue which connects the lid with the globe or with 
the surface of the cornea. In others it is associated with dermoids of the 
corneoscleral region or with subconjunctival lipomas. In still other cases 
corneal opacities or pterygium-like formations are present (von Hippel). 

Cryptophthalmos.-—Under this name Zeliender and Manz have de¬ 
scribed a congenital condition in which the chief characteristic is the passage 
of skin over the base of the orbit, completely hiding the eyeball. The name 
is incorrectly applied to a similar condition of the skin with absence of the 
globe. In most cases of cryptophthalmos other defects are present. The 
affection was bilateral in six and unilateral in three of the reported cases. 
Cilia, eyelids, and conjunctival sacs were absent. The eyebrows were present 
in two cases. Perception of light is present in cryptophthalmos, as is evi¬ 
denced by contraction of the skin over the globe when light is concentrated 
on the base of the orbit. The condition is irremediable. 

Symblepharon.—This is a cohesion between the eyelid and the eye¬ 
ball, and may be partial or complete. In cryptophthalmos there is com¬ 
plete obliteration of the conjunctival sac. Partial adhesion of the lid to 
the globe is sometimes seen as a congenital condition. 

(158) 


DISEASES OF THE EYELIDS. 


159 


Ankyloblepharon, union between the lid-margins, may be total or 
partial. A few cases have been observed in which at birth a filiform band 
passed from one lid to the other. 

Blepharophimosis, an adhesion of the lids at the outer canthus, pro¬ 
ducing a narrowing of the palpebral opening, may occur congenitally. The 
author has observed it as an hereditary characteristic. 

Microblepharon, a congenital shortening of the lids, has been observed 
by Fuchs and others. 

Entropion, a turning in of the eyelid, when congenital is generally 
associated with other anomalies, such as distichiasis, epicanthus, anoph- 
thalmos, or microphthalmos. 

Ectropion, a turning out of the lid, when congenital is often found in 
association with hydrophthalmos, ptosis, microphthalmos, epicanthus, or 
anoplithalmos. 

Distichiasis, the presence of rows of supplementary cilia, has been 
studied by Ivuhnt, who found that in lids otherwise normal a second row 
of very fine hairs grew from the posterior part of the intermarginal space. 
Study of sections of the lid showed the entire absence of Meibomian glands, 
the abnormal cilia occupying their places. The glands of Moll and Krause 
were consequently uncommonly well developed. According to Westhoff, 
congenital distichiasis is sometimes hereditary. 

Epicanthus.—This is a condition in which relaxed folds of skin at the 
root of the nose extend vertically toward the eyebrows. In pronounced 
cases they conceal the inner canthus, caruncle, and in some instances the 
inner half of the lid, giving the appearance of strabismus. It is almost 
always bilateral and often is associated with ptosis. In Mongolians it is 
a normal condition. A small amount of deformity existing at birth will 
often disappear in a few years with the development of the nose. When the 
skin of the root of the nose is lifted up, the deformity disappears: an 
observation which caused von Ammon to devise his operation for epicanthus. 
A spurious form of epicanthus is acquired by syphilitics with saddle-noses. 
The treatment of epicanthus is chiefly surgical. Broekaert and others have 
reported successful results from the subcutaneous injection of paraffin, which 
is molded into the desired form and heightens the nasal bridge. 

Congenital Ptosis, a drooping of the upper lid, may be unilateral or 
bilateral, and often is associated with epicanthus, paralysis of the ocular 
muscles, or other congenital anomalies. It may be due to redundancy of 
tissue or to deficient development or absence of the levator muscle. Ptosis 
should be corrected by operation. 

Fistula of the Upper Lid.—This is an extremely rare condition due to 
non-closure of the fronto-maxillary fissure. One case has been described 
by Lannelongue and Menard. 

Treatment of Congenital Anomalies.—The treatment of these condi¬ 
tions is entirely surgical, and does not differ from that applied to similar 
acquired affections. 


160 


MODERN OPHTHALMOLOGY. 


SKIN DISEASES OF THE EYELIDS. 

The skin diseases of the eyelids are numerous. No attempt will be 
made here to properly classify them. A short description of the principal 
ones will be sufficient for the purposes of the ophthalmologist. 

Erythemata.—The erythematous affections of the eyelids are similar 
to those which involve other portions of the integument. They properly 
belong to the domain of the dermatologist, but frequently fall into the hands 
of the oculist on account of the concomitant conjunctivitis which requires 
his attention. The one most frequently seen is 

Erythema Simplex, an active hyperemia whose causes are various and 
which disappears upon their removal. This active hyperemia is best com¬ 
bated by cooling evaporating lotions. It is easily recognized as a diffuse 
flush, of a rather bright color, and is to be distinguished from erysipelas, 
which is a specific inflammatory trouble. A form of passive hyperemia, 
sometimes observed, is that due to venous stasis. Here the lids have a 
bluish-purple hue. The cause of the stasis must be sought and corrected, 
or a greater or less amount of cliemosis will result. 

Urticaria (Hives) is an inflammatory disorder of the skin, often in¬ 
volving the eyelids. It is characterized by the presence of wheals with a 
sensation of itching and burning. In the vast majority of cases it is of 
gastric origin. It has been seen to follow upon eyestrain or upon improperly 
corrected errors of refraction (Oliver). The disease should be treated by 
removal of any source of irritation. The use of an antacid, with proper 
regulation of the diet, will usually give relief. The chronic form, known 
as .cnidosisj should be treated with pilocarpin, quinin, and bromids inter¬ 
nally. It may continue for years in spite of treatment. 

The inflammatory skin affections of the lids are not so easily allayed, 
and constitute quite a large class. They are often prone to be obstinate, 
and local treatment alone will not suffice, but must be combined with 
internal measures. The most commonly observed of this class is perhaps 
eczema in its different stages. 

Eczema of the Eyelids occurs both in children and in adults, in con¬ 
nection with eczema of the face. 

In children it is the rule that the lids are not involved. Infantile 
eczema assumes three forms: the neurotic, the seborrheic, and the strumous. 
Neurotic, or reflex, eczema arises from gastroenteric disturbance, and is 
seen in otherwise healthy, well-nourished children. While the forehead, 
cheeks, and chin may be bleeding, a trefoil, which includes the orbits, nose, 
and mouth, is exempt. This is the most frequent type of infantile eczema. 
In the seborrheic and strumous types the eyelids are often involved. In 
the latter variety fissures are often present about the canthi, as well as at 
other mucocutaneous junctions. 

In adults eczema of the lids is almost invariably of the erythematous 
type. Eczema of the lids may show papules, scales, or pustules. All forms 
itch. Conjunctivitis is often present. 


DISEASES OF THE EYELIDS. 


161 


Treatment should be adapted to the variety and stage of the disease. 
Care should be taken to avoid irritating applications. To prevent agglutina¬ 
tion, an ointment of the benzoated oxid of zinc may be applied to the lids 
at night. The conjunctivitis should receive appropriate treatment. The 
habits and diet should be regulated. In the strumous form of eczema the 
syrup of the iodid of iron with codliver-oil should be administered. In the 
seborrheic form the diet should be regulated and a sulphur ointment should 
be applied locally. The concomitant skin affection should be treated by 
a competent dermatologist. Otherwise repeated reinfection of the lid- 
margins will occur. 

Fissures of the External Canthus (Rhagades) are often present in 
cases of eczema and in types of ocular disease causing photophobia and 
blepharospasm, viz.: conjunctivitis and keratitis. The raw spots should be 
touched with nitrate of silver, either in the form of a strong solution or the 
solid stick. In obstinate cases canthotomy may be required. 

Impetigo of the eyelids is uncommon, and manifests itself as pustules 
of a split-pea size, which disappear spontaneously in a few Aveeks. There are 
no subjective lesions. Tonic treatment and antiseptic applications are suffi¬ 
cient. 

Furuncle.—This form of localized inflammation of the skin and sub¬ 
cutaneous tissue, due to infection by one or more of the pus-cocci, is occa¬ 
sionally seen on the eyelids. The local use of an ointment of salicylic acid 
(gr. xv to ,jj), and the occasional application of cloths wrung out of hot 
water, will be appropriate. In neglected cases an incision will be necessary. 

Frambesia (Yaws; Amboyna Button; Pian).—This is a contagious 
disease met with in tropical climates. It is characterized by the presence 
of raspberry-like nodules in the skin and by more or less constitutional dis¬ 
turbance. The papules rind ergo suppuration and scabbing, with the forma¬ 
tion of a slight scar. In some instances there is serious ulceration of the 
skin and subcutaneous tissues. The entire course of the disease occupies 
several months. The eruption, which begins on the face and extends down¬ 
ward, may involve the eyelids, leading to localized thickening, conjunc¬ 
tivitis, and sometimes necrosis. Yaws is to be differentiated from small¬ 
pox and the lesions of hereditary syphilis. Its marked resemblance to 
blastomycetic dermatitis has been recently noted. The prognosis is gen¬ 
erally favorable. The treatment includes improved hygienic surroundings, 
tonics, diaphoretics, and local applications of carbolic-acid lotion or the 
diluted nitrate-of-mercury ointment. 

Furunculus Orientalis (Aleppo Boil; Delhi Boil; Biskra Button).— 
These names indicate a local infectious disease endemic in the tropics, and 
characterized by the formation of papules, nodules, scabs, and punched-out 
ulcers. The uncovered parts of the face are chiefly attacked. The disease 
is inoculable in both men and animals. Laveran attributes its spread to 
flies. It is to be distinguished from yaws, which presents marked consti¬ 
tutional symptojns, and is found almost entirely among the colored races. 


162 


MODERN OPHTHALMOLOGY. 


The oriental boil is a local disease, without constitutional disturbance, and 
occurs among all tropical races regardless of color. The prognosis is favor¬ 
able. The treatment includes the use of the galvanic cautery in the early 
stage; hypodermic injections of 10-per-cent, carbolic solution around the 
boil; and curettement or the application of caustics, when the process has 
gone on to suppuration and the formation of granulations. The eyelids are 
often involved in this disease. 

Malignant Pustule (Anthrax Pustule).—This disease, due to inocula¬ 
tion with the anthrax bacillus, may involve the eyelids. It is transferred 
to man from infected animals, and is found among persons who are em¬ 
ployed in the care of animals and among those who handle hides and wool. 
The infection is carried by the hands, by dirty instruments, or by the bites 
of insects which have fed on the cadavers. The disease, which fortunately 
is rare in this country, begins as a small vesicle surrounded by an areola. 
Soon a livid-red papule develops, followed by a bulla or pustule, and this, 
in turn, by a black eschar. There is a broad area of edematous infiltration 
of a violet color. The gangrene may spread rapidly and terminate fatally, 
or a localized slough may be thrown off, leaving an ulcer, which heals by 
granulation. When the eyelids are involved there may be extensive de¬ 
struction, only the ciliary margins remaining. The constitutional symptoms 
are those of sepsis. The diagnosis will rest on the history of the case, the 
appearance of the lesions, and the finding of the anthrax bacillus. The 
prognosis is serious, from 30 to 50 per cent, of the cases ending fatally. 
The treatment will embrace general supportive measures, incisions, the use 
of the galvanic cautery to destroy the infected area, and the application of 
biclilorid solutions. After recovery a plastic operation may be required. 
Where there is extensive loss of tissue, it will be advisable to suture the 
marginal portion of the lid to its fellow to prevent lagophthalmos and 
ectropion. 

Carbuncle, an acute phlegmonous inflammation, circumscribed, but 
more extensive than that of furuncle, may occur upon the eyelids, and is 
attended with sloughing of the tissues and gangrene of the skin. It should 
be treated by multiple incisions, curettement of the sloughing material, and 
packing with gauze. In the treatment care should be taken lest injury be 
done to the eyeball. A canthotomy may be needed to relieve pressure on 
the globe. 

Abscess of the Lid may occur as the result of injury or orbital disease 
or from causes not well understood. It should be treated by incision parallel 
with the fibres of the orbicularis muscle. 

Tarsitis, inflammation of the so-called tarsal cartilage, occurs chiefly in 
syphilitic subjects, and is characterized by great thickening of the lid-mar¬ 
gin, often producing considerable deformity. Acute tarsitis is associated 
with conjunctivitis, blepharitis, and sloughing of the tissues. It is found 
also in scrofulous subjects. Syphilitic tarsitis occurs as a tertiary symptom. 
The upper lid droops from increased weight; in tarsitis of the lower lid 


DISEASES OF THE EYELIDS. 


1G3 


ectropion is not uncommon. The treatment includes local cleanliness and 
the application of remedies suitable for blepharitis, such as ointments of 
the yellow oxid of mercury, ointment of ammoniated mercury, etc. Inter¬ 
nally antisyphilitic remedies are to be used. 

Erysipelas.—Although the eyelids are often involved in erysipelas, the 
disease rarely begins in them. The lids show a dusky-red color; they are 
edematous and soft; there is great enlargement, the swelling extending over 
the eyebrow and cheek; the skin presents numerous small blisters, and 
chemosis and conjunctivitis are often present. By extension into the orbit 
the disease may cause exophthalmos, atrophy of the optic nerve, and even 
meningitis and death. The general and local treatment is the same as for 
erysipelas located elsewhere. Local applications of ichthyol are valuable. 

Herpes Zoster Ophthalmicus (Herpes Frontalis) is a form of herpes 
which, by reason of the ocular symptoms, is of interest to the ophthalmic 
surgeon. While the disease occurs most frequently in elderly and feeble 
patients, it is not rarely observed in children and in young subjects with ap¬ 
parently unimpaired nutrition. The initial symptoms include severe pain 
limited to one side of the head and face, rise of temperature, anorexia, chills, 
and, in some cases, bronchitis. After the pain has been present for from 
one to three days unilateral involvement of the skin is apparent along the 
course of the branches of the first (ophthalmic) division of the fifth nerve, 
the second and third divisions being rarely involved simultaneously. The 
eruption begins with groups of papules, .rapidly changing into vesicles which 
vary in size from a pin’s head to a split pea. These are surrounded by a 
bright-red areola. They rapidly become cloudy and form dry crusts. The 
vesicles occur in patches of three or more, having a tendency to group in a 
round form. They appear in the temporal region, on the forehead, upper 
lid, conjunctiva, and cornea. The lower eyelid and cheek are rarely involved 
in the eruption. The cheek, however, may be edematous by contiguity. The 
cornea is not always involved in ophthalmic herpes. Many years ago Hutch¬ 
inson observed that the cornea is involved only in case the nasal nerve is 
affected. After a variable time the skin heals, leaving pits and depressions 
resembling those of small-pox. From the peculiar grouping of the scars, 
it is possible to recognize the disease long after its subsidence. Early in the 
disease the cornea becomes cloudy; often a large bleb forms, and this, on 
breaking, leaves an ulcer which frequently causes a scar. Iritis, conjunc¬ 
tivitis, iridocyclitis, and even panophthalmitis are sometimes observed in 
these cases. Barrett has reported two cases in which diplopia was pres¬ 
ent. Tension is often increased in the acute stage of the disease and is 
subnormal in the later period. Rarely ophthalmic herpes is a cause of sym¬ 
pathetic ophthalmitis. Long after the acute symptoms have disappeared 
the eyeball remains anesthetic, although subject to attacks of neuralgic pain, 
and the skin feels numb and stiff like parchment. The prognosis is serious 
as regards visual acuity. Vision is much reduced, either by the presence of 
a corneal scar, by changes incident to iridocyclitis (posterior synechiae, etc.), 


164 


MODERN OPHTHALMOLOGY. 


or from atrophy of the optic nerve. The disease is of long duration, often 
lasting for months. 

Pathology.— The lesions in herpes zoster ophthalmicus are found in 
the Gasserian ganglion and in the branches of the fifth nerve supplying the 
affected area. The first satisfactory report on the ’ pathologic changes in 
this disease was given by Sattler in 1875, who found inflammatory lesions, 
with hemorrhages destroying the nerve-cells and fibres of the Gasserian 
ganglion. The ophthalmic division of the nerve was degenerated. The 
correctness of Sattler’s findings has been confirmed of late by Head and 
Campbell, of London. 

Diagnosis.- —Herpes zoster ophthalmicus in former years was often 
mistaken for erysipelas: a mistake which should not occur. The former 



Fig. 140.—Herpes zoster ophthalmicus. (Fuchs.) 

Appearance five days after the beginning of the disease. The vesicles follow the course of the 
frontal and nasal branches of the ophthalmic division of the fifth nerve. 


disease is always limited to one side, never crossing the median line of the 
forehead or nose. There is more pain and less constitutional disturbance in 
herpes than in erysipelas. The vesicles of herpes are smaller, more numer¬ 
ous, and more circumscribed than the bullae of erysipelas. 

Treatment. —The treatment of this disease must be symptomatic. 
Elderly persons will require ferruginous preparations, tonic doses of quinin, 
and occasionally stimulants. Morphin or holocain may be needed to relieve 
the pain. Other measures for the relief of pain are the internal use of 
phosphid of zinc (gr. 1 / 3 three times a day) and the application of the 
galvanic current. The positive pole should be placed at the vertex while 
the negative is applied to the affected area. The pupil is to be dilated with 
atropin. If tension becomes increased, as sometimes occurs in the height 



DISEASES OF THE EYELIDS. 


165 


of the disease, paracentesis of the cornea should be done. The skin lesions 
are best treated with drying powders or soothing ointments. Of the latter, 
the following is recommended :— 


R Cocain .gi\ x. 

Bismuth subnitrate .3iss. 

Simple cerate.gj. 


Mix and apply locally. 

The following internal remedies may be used in children and adults, 
the doses for children being modified according to age. For adults: — 


R Acidi arsenosi.gr. j 

Pulvis piperis nigri.oij. 

Extracti gentian* .q. s. 


M. Fiat capsulae No. xxx. 

Sig.: One capsule after each meal. 

Pemphigus. — Bullous affections of the eyelids, such as dermatitis 
herpetiformis and pemphigus, are occasionally seen. In the former the 
lesions are small and grouped; in the latter they are large and scattered. 
Being diseases subject to frequent relapses, care must be exercised in 
formulating a prognosis. The treatment of these conditions is outside the 
domain of ophthalmology. Essential shrinking of the conjunctiva some¬ 
times accompanies pemphigus. Contagious impetigo and various septic 
conditions may occasion acute processes attended with the formation of 
bullse about the lids. 

Lichen Ruber, Lichen Planus, and Lichen Scrofulosus occur so rarely 
on the eyelids and are so difficult to recognize, as well as to treat, that they 
should be referred to a dermatologist. 

Dermatitis, if it involves the face, will also manifest itself upon the 
eyelids. The symptoms presented are those of acute inflammation. The 
most common form is that of dermatitis venenata, or poisoning, which 
brings about a severe cliemosis and a marked conjunctivitis. In rims poi¬ 
soning, due to contact with “poison-ivy” or “poison-oak,” the skin is of 
a deep-red color and the subcutaneous tissue is edematous. Patches of 
vesicles are present which furnish a yellowish fluid. On drying, this forms 
a crust. Burning and itching are distressing symptoms. The disease is 
self-limited. As soon as discovered the affected area should be thoroughly 
washed with soap and water. When the skin is unbroken, applications of 
dilute lead-water will give relief. Locally we may apply the fluid extract 
of grindelia robusta, diluted 1 part to 30 of water. A valuable application 
consists of equal parts of tincture of sanguinaria and water. 

Dermatitis Medicamentosa is often seen to manifest itself on the eye¬ 
lids. Belladonna, quinin, the turpentines, copaiba, antipyrin, arsenic, iodid 
of potassium, iodoform, mercury, and other internal remedies may produce 
this inflammation, which is best allayed by soothing applications and the 
discontinuance of the causative drug. 








166 


MODERN OPHTHALMOLOGY. 


Blastomycetic Dermatitis, a rare, chronic, local infective process, be¬ 
ginning as a papule or papulo-pustule, often involves the lids. “The lesion 
slowly enlarges peripherally in the form of an indolent, flat, wart-like, or 
crusted papule” (Montgomery). The surface shows irregular papilliform 
elevations between which pus oozes on pressure. The border of the lesion 
is of a purple or reddish color, and is studded with minute abscesses, which 
can be easily recognized with a magnifying glass. The disease may remain 
indolent for months or years, with occasional exacerbations. The lesions 
may heal centrally while extending peripherally. The disease, when in¬ 
volving the eyelid, causes ectropion. Blastomycetic dermatitis is to be 
differentiated from syphilis, carcinoma, lupus vulgaris, and verrucous tuber¬ 
culosis. The characteristic features are the miliary abscesses and the pres¬ 
ence of distinct budding organisms seen on microscopic examination. The 
treatment includes excision of the diseased areas, which has been success- 



Fig. 141.—Blastomycetic dermatitis involving the eyelids. (Walker.) 


fully practiced in several cases, the internal use of large doses of potassium 
iodid, and exposure to the x-rays. Cleansing or antiseptic washes or dry 
dressings can be used locallv with benefit. 

Perifolliculitis (Hordeolum; Stye).—This is an inflammation of one 
of the glands of the follicles of the eyelashes (Zeiss’s glands). The term 
internal hordeolum is applied to an inflammation of a Meibomian gland. 
These affections are easily recognized as circumscribed inflammatory areas. 
They are produced by two factors: hyperemia and infection. Hyperemia 
may be due to one or more of various causes, including eyestrain from 
uncorrected or improperly corrected errors of refraction, catarrhal con¬ 
junctivitis, nasal polypi, hypertrophic rhinitis, alcoholism, etc. Infection 
is frecpiently transferred from a seborrheic eczema of the scalp by the 
hands. This fact has hitherto been overlooked by most ophthalmologists. 
Since itching exists, the patient’s efforts to relieve this symptom will often 










DISEASES OF THE EYELIDS. 


167 


cause the spread of the disease to adjacent follicles. The crusts, resulting 
from desiccation of the pus, easily convey infection. Hence immediate 
treatment is indicated. The disease does not occur upon the eyelid proper, 
because no hairs exist upon it. 

Treatment. —In the early stages the application of very cold or of 
very hot packs may abort the process. If this does not succeed, pus will 
form. If the horny epithelial layer be carefully split open, the deposit of 
pus in the form of a small sphere can be squeezed out and no more 
hordeola will occur. The incision should be made in a direction parallel 
with the course of the fibres of the orbicularis muscle. Antiseptic washes 
can be applied to the inflamed area. Internal hordeola are to be opened 
and evacuated from the conjunctival surface. In the type due to infection 
from seborrheic eczema, the patient should receive treatment from a com¬ 
petent dermatologist. Otherwise reinfection will occur repeatedly. 

Congenital Hyperkeratosis.—In congenital hyperkeratosis of the skin, 
usually confounded with ichthyosis, the skin of the face and eyelids may 
be involved. Subjects of mild grades of the disease, who survive, some¬ 
times show ectropion, loss of eyelashes and eyebrows, conjunctivitis and 
keratitis, symblepharon, and atrophy of the conjunctiva. The treatment 
should include alkaline and bran baths to loosen the scales, and the appli¬ 
cation of unctuous substances, of which lanolin is one of the best. The 
internal use of thyroid extract has been advised. 

Chloasma is a pigmentary hypertrophy frequently found as a result of 
pregnancy and uterine diseases. In many instances the dark pigmentation 
is found upon the eyelids and in the neighborhood of the eyes. The treat¬ 
ment is difficult. Care must be exercised in the application of whatever 
remedy is employed, since all must necessarily be more or less irritating. 
Strong bichlorid solutions are probably the best. 

Discoloration of the Eyelids is occasionally seen as a result of drug 
ingestion or accident. Thus, argyria, seen but seldom now, is due to the 
internal use of nitrate of silver. Siderosis, which shows itself as small 
brown spots, is due to the penetration of the skin by small pieces of steel. 
Accidental tattooing of the eyelids, chiefly by grains of powder, is a com¬ 
paratively common occurrence. In recent cases of powder-burn the best 
results are obtained by placing the patient under a general anesthetic and 
using a nail-brush under aseptic precautions. If seen after the carbonized 
particles have stained the integument, puncture with the electrolytic needle 
will give satisfactory results, although the treatment is tedious. 

Dermoid Tumors are rarely found in the eyelids. A favorite site is 
the region of the external angular process of the frontal bone. Rarely is 
the tumor found in the eyebrow. Less frequent are dermoids located at the 
inner angle of the upper lid. In this location the growth may have a 
pedicle connected with the dura mater, resembling a meningocele, in that 
the brain pulsation is communicated to it. Sutton states that dermoids 
found in the upper eyelid, unconnected with bone or periosteum, probably 


1G8 


MODERN OPHTHALMOLOGY. 


arise in the fissure between the fronto-nasal plate and the fold of skin from 
which the lid is formed. The treatment of dermoids is excision. 

Verruca, or wart, is occasionally seen upon the eyelids. The most 
common form in this locality is the so-called filiform variety, which is 
chiefly found in old persons. It is always advisable to cause the disappear¬ 
ance of these growths by acids, caustics, or surgical means, the best of which 
latter is electrolysis. 

Cornu Cutaneum, or cutaneous horn, of the eyelids is comparatively 
small and generally involves the lower lid. It occurs in middle life, and 
its extirpation, with cauterization of the base, is to be advised. Epithelioma 
is said to be likely to follow if its spontaneous fall is permitted to occur. 

Lipoma.—Fatty tumors are rare in the eyelids. They are circum¬ 
scribed, soft, elastic, and lobulated. They should be excised. 



Hernia of the Orbital Fatty Tissue.—The fatty tissue of the orbit is 
normally held in place by the tarso-orbital fascia, orbicularis muscle, and 
skin. As a result of atrophy in elderly persons, or from trauma at any 
period of life, these tissues may become weakened and permit of protrusion 
of the orbital fat between the orbicularis muscle and the skin. The hernia 
can be pushed backward into the orbit. If of sufficient size to cause de¬ 
formity, the protruding tissue may be readily removed through an incision 
made parallel with the orbicularis fibres. 

Edema of the Lids is a common condition. It is often found following 
trauma, and is a frequent accompaniment of inflammation of the con¬ 
junctiva or infection after operations on the globe. It is found in con¬ 
nection with diseases of the orbit. It may follow probing of the lacrimo- 
nasal duct or the injection of fluids into the adjacent tissues. It occurs 
in renal and cardiac diseases, arsenical poisoning, malaria, etc. In these 




DISEASES OF TIIE EYELIDS. 


1G9 


conditions the edema is more marked when the patient is recumbent. In 
such diseases the swelling is pale and translucent. The edema due to 
inflammatory conditions is reddish, opaque, tense, and shining. Being 
merely a symptom, it does not usually call for treatment. When so exten¬ 
sive as to prevent opening of the eye, it can be relieved by puncture and 
the use of a compress bandage. 

Solid Edema of the Lids.—This term is applied to a condition in which 
there is enormous enlargement of the eyelids, particularly of the lower lid. 



Fig. 143.—Verruca of the eyelids. (Von Ammon.) 


The swelling, which is often so great as to conceal the palpebral fissure, is 
soft and elastic, pits on pressure, is of a dusky reddish-brown color, without 
evidences of inflammation and without involvement of other parts of the 
body. In the majority of cases the disease has followed attacks of ery¬ 
sipelas. Some of the cases have terminated in tuberculosis of the con¬ 
junctiva. The nature of the disease is obscure. It is supposed to be a 



Fig. 144.—Cornu cutaneum. (Sciiaw.) 


recurrent lymphangitis. Various methods of treatment—nitrate of silver, 
collodion, pressure, fomentations, multiple punctures, and excision—have 
been tried without permanent benefit. 

Elephantiasis Arabum.—This rare disease sometimes involves the eye¬ 
lids. It may be divided into two classes: (1) the tropical endemic type, 
which is due to filaria sanguinis hominis; and (2) the sporadic type, 
which is attributed to a variety of causes, all of which produce blocking 
of the lymph-channels. Thus, it follows oft-recurring attacks of ery- 





170 


MODERN OPHTHALMOLOGY. 


sipelas. In the case reported by Walzberg (Fig. 146) hypertrophy of the 
left upper eyelid was present at birth. Attacks of inflammation preceded 
increased growth. The eyeball was displaced, the eye was amaurotic, and 
the cornea was hazy. The mass was successfully operated upon by Koenig. 
The pathologic changes in elephantiasis of the lids are an hypertrophy of the 
skin, particularly of the subcutaneous connective tissue, and dilation of the 
lymph-spaces, which are blocked, thus leading to lymphatic edema. The 
treatment consists in massage and surgical measures. 

Lentigo (Freckles).—Small circumscribed spots or splotches of pig¬ 
ment occur on the eyelids as well as on other exposed portions of the skin. 



Fig. 145.—Solid edema of the eyelids. (Critchett.) 


They usually appear about the second decade of life, but may be congenital. 
They do not call for treatment. 

Varicose Veins.—Dilated and tortuous veins are occasionally seen in 
the lids, particularly in the upper lid (Fig. 147). 

Naevus Pigmentosus, or pigmentary mole, is a congenital growth 
occurring either singly or in numbers. The form is oval or circular. The 
size varies from a pinhead to large tumor-like masses. The upper eyelid 
is more often involved than the lower. There are smooth, warty, fatty, and 
hairy moles. The treatment is surgical. For the larger ones excision is 
indicated, and, for the smaller, electrolysis is the best method. 

Vitiligo and Albinism, the one acquired and the other congenital 
deficiency of the pigment of the skin, are similar in appearance, presenting 
a milky-white color of the integument. In the latter there is absence of 





DISEASES OF THE EYELIDS. 


171 


pigment in the chorioid, and nystagmus is often observed. There is no 
efficient treatment for either condition. 

Xeroderma Pigmentosum (Kaposi’s Disease). — This rare disease, of 
which about one hundred examples have been recorded, in most cases 
presents noteworthy ocular symptoms. The affection begins in early infancy 
with the advent of minute freckle-like spots of a brown or black color. 



Fig. 146.—Elephantiasis of the upper eyelid. (After Walzberg.) 


elevated, flat or nodular, which develop under the influence of light. Its 
first appearance is upon the face and hands. Between the freckle-like spots 
are areas of depigmented skin, forming white islands. In the next stage 
large telangiectases appear, and finally the skin becomes atrophic, smooth, 
and degenerated. The skin of the eyelids is involved, and blepharitis, 
conjunctivitis, pigment-spots, and telangiectases of the conjunctiva and 



Fig. 147.—Varicose vein of the upper eyelid. (Author.) 

(Original drawing by Miss Augusta Bierman.) 

ulcers of the cornea are often present. The stage of atrophy is followed 
by the appearance of multiple wart-like elevations, which undergo car¬ 
cinomatous or sarcomatous degeneration. These growths arise more fre¬ 
quently from the eyelids than from the eyeball. They ulcerate, forming 
fungous masses. Early in the history of the case the eyelashes fall out. 
The etiology of xeroderma pigmentosum is unknown. The prognosis is 



MODERN OPHTHALMOLOGY. 


1 i^O 
1 i 6 

unfavorable, most of the patients dying early of multiple carcinoma. 
Treatment so far has been without value. Panas and Monthus advise 
excision of the neoplasms, with cauterization of their bases. 

Keratosis Follicularis (Darier’s Disease).-—This rare disease begins on 
the face or trunk, and involves the lids. It appears as a papule the size 
of a lentil or pea, of a dirty-red color,'having a brown, black, or gray horny 
crust, which plugs a sebaceous duct. It is a rebellious affection, and should 
be referred to a dermatologist for treatment. 

Molluscum Epitheliale, also known as molluscum contagiosum, is un¬ 
usual, but is easily recognized. The lesions present the appearance of warts 
and are rather translucent, the largest being umbilicated. The disease is 
generally considered to be contagious and autotransferable. It is seen most 
frequently in children, and the eyelids are frequently attacked. The treat¬ 
ment is simple, consisting in enucleation of the sac and its contents. 
Electrolysis may be employed or an application of acid-nitrate-of-mercury 
ointment can be made. 

Xanthoma derives its name from the yellow color which its lesions 
present. It is found in two forms: the plane and the tubercular. The 
former occurs as oval or crescentic macules varying in size from a pinhead 
to the thumbnail. The color is that of straw or sulphur yellow. The 
lesions present the appearance of a piece of chamois set into the skin. 
The macules occasionally become confluent, and are most frequently seen 
on the upper eyelid near the inner canthus. The tubercular form is of 
rare occurrence in this situation. Cholesterin crystals occur in abundance, 
there being also a marked number of new cells known as xanthoma bodies. 
The condition is accompanied by a fatty degeneration which, according to 
Pollitzer, in this situation affects the fibres of the orbicularis palpebrarum 
muscle. The treatment of this condition is generally unsatisfactory. Elec¬ 
trolysis has given good results in a few instances. The x-ray has recently 
been recommended. 

Lupus Erythematosus is occasionally seen to involve the eyelids by 
extension of the process from the cheeks. It is difficult to diagnosticate 
and to treat, and it rarely occurs that the ophthalmologist is called upon 
to treat it. A large proportion of dermatologists look upon it as a form 
of tuberculosis of the skin. 

Tuberculosis.—True tuberculosis of the skin is a disease of great rarity. 
It is found in the form of discrete, shallow, painless ulcers with eroded, 
irregular edges. When the crusts are removed a reddish-yellow granular 
surface is exposed. The ulcers never heal. They spread continuously, and 
coalesce with other ulcers to form large areas. Crocker states that the diag¬ 
nosis is difficult in the absence of signs of general tuberculosis. The disease 
is found in regions where the skin and mucous membrane join. Since 
tubercle bacilli are found in lupus vulgaris, scrofuloderma, tuberculous 
ulceration, and tuberculosis verrucosa cutis, the term tuberculosis of the 
skin is loosely applied to affections which, however similar they may be 


DISEASES OF THE EYELIDS. 


173 


microscopically and pathologically, present marked clinical differences 
(Crocker). Tuberculosis of the skin offers an unfavorable prognosis. 

Lupus Vulgaris, which is common on the European continent, is rare 
in this county. When present upon the face or nose it may extend to the 
eyelids. It is characterized by the presence of papules, nodules, and patches, 
which either ulcerate or atrophy, leaving scars. It almost invariably appears 
before puberty, and is more frequent in females than in males. It begins 
as pinhead spots of a reddish color which change into nodules. These 
present a brownish, translucent appearance, likened by Hutchinson to apple- 
jelly. After a time, which may be months or years, the nodules coalesce, 
become elastic to the touch, and ulceration occurs, which spreads and cic¬ 
atrizes spontaneously. When the eyelids are attacked there may lie cica¬ 
tricial ectropion, or the lids may be entirely destroyed. In the latter case 
the eyeball will be attacked. The disease, which is of long duration, may 
remain unrecognized until seen by a dermatologist, since the diagnosis is 
difficult. The treatment is complete removal of the diseased tissue. 

Syphilis.—Syphilis of the eyelid may be present as primary, secondary, 
or tertiary lesions, or as hereditary manifestations. Cliancra (Fig. 7, Plate 
VII) presents as an ulcer with indurated base. Until the development of 
secondary symptoms the diagnosis may be in doubt. The conditions with 
which it is most likely to be confounded are the pustules of vaccinia and 
tuberculous ulcer. In chancre the pre-aurieular gland is always, and the 
submaxillary is frequently, indurated. Only a careless or incompetent 
observer could mistake a chancre for a stye, chalazion, or dacryocystitis. 
Chancre may appear at any period of life. It is more often found on the 
lower than upper lid, and in men more frequently than in women. The 
infection may be carried by unclean fingers, towels, instruments, by kissing, 
or by the practice, common among Russians, of removing foreign bodies 
by licking. Tepljaschin, in a small town in Russia, met with thirty-four 
cases of chancre of the eyelids caused by a female quack who treated granular 
conjunctivitis by everting the lids and licking them. Hot infrequently 
physicians, while treating the throats of syphilitics, have become inoculated 
by the patient’s saliva projected by coughing. In the treatment use may 
be made of the yellow wash locally and mercury internally or by inunction. 
The prognosis is favorable. 

Serpiginous Syphilide of the Eyelid may closely resemble lupus 
or tuberculosis, and produces extensive destruction unless checked by appro¬ 
priate internal treatment. 

Gumma is probably the most frequent of the syphilitic diseases of the 
lids. The lid becomes swollen and tense. Ulceration follows, the ulcer 
having an irregular, eroded, “punched-out” appearance. Its floor is cov¬ 
ered with dirty-yellowish or gray debris , and if unchecked there may be 
extensive destruction of the tissues. In the absence of a history of infection 
the diagnosis may be difficult. The syphilitic ulcer presents an infiltrated 
base, but not the parchment-like indurated base of chancre (de Beck). 


174 


MODERN OPHTHALMOLOGY. 


Rodent nicer is found in older persons, as a rule. Tubercular ulcers of the 
eyelid have their origin in tuberculosis of the conjunctiva. They are ex¬ 
ceedingly rare. There is a profuse purulent discharge and early involvement 
of the cornea. A suppurating chalazion or hordeolum will give a different 
history and will run a different course. The prognosis of gumma of the lid 
is favorable, the condition yielding to iodid of potassium internally and 
mercurial salve locally. Cauterization is contra-indicated. 

Leprosy is a general affection of the human organism and one not 
easily recognized by the non-expert. So far as the eyelids are concerned, 
its local forms are thickening of the lids, the presence of tubercles upon 
them, or ulceration of the tissues. The eyebrows and eyelashes are apt to 



Fig. 148.—Gummata of the eyelids. (Keber.) 


turn white or they may drop out. In advanced cases of anesthetic leprosy, 
when mutilations occur, there is observed an ulcerated process involving the 
eyelids and even the ocular globe. A distinguishing symptom between this 
and lupus is the total absence of pain in the former. All treatment for 
leprosy has proven ineffectual, although chaulmoogra-oil is said to be 
useful. Recently the hypodermic injection of Calmette’s antivenene serum 
has given promise of good results (Dyer). 

Keloid is a connective-tissue neoplasm which rarely attacks the eve- 
lids. It is frequently the result of a traumatism, and is often seen in the 
negro or one who has in him negro blood. The treatment is unsatisfactory. 
Electrolysis or the x-ray may be tried. 





DISEASES OF THE EYELIDS. 


175 


Plexiform Neuroma of the Eyelid (Neurofibroma) is a rare growth 
which is really a fibroma developing from the sheaths of peripheral nerves, 
there being no new development of nerve-fibres. The growth, which shows 
a peculiar predilection for the upper eyelid, is either congenital or appears 
in early infancy. The lid becomes greatly enlarged and of elephantiasis¬ 
like appearance, and ptosis results. The tumor is soft in general, with 
localized cord-like spots which can be traced backward into the orbit. In 
some of the recorded cases the face and eyeball have been involved. Usu¬ 
ally the growth is not painful. The adjacent skin presents numerous spots 
of brownish-yellow color. Microscopically such growths are composed of 
nerve-bundles imbedded in masses of connective tissue. The treatment is 
excision. If incompletely removed the growth will return. 

Fibroma of the Eyelid.—This disease, known also as the painful sub¬ 
cutaneous tubercle of Wood, may be found in the lid as a small, hard, 
rounded mass, usually remaining stationary after reaching a certain size. 
It is subject to attacks of radiary pain. Such a growth is usually freely 
movable, and its true nature is likely to be revealed only after removal. 
Microscopic section shows the mass to consist of bundles of densely packed 
fibrous tissue containing numerous blood-vessels. 

Naevus Vasculosus is frequently seen and is easily recognized. It is 
congenital and occurs about the eyelids not infrequently. Naevi are round¬ 
ish or irregular in shape and size, and bright red, violaceous, or blue in 
color. They are very vascular, being essentially composed of dilated or 
hypertrophied blood-vessels. Angioma cavernosum is very vascular and 
at times pulsating; angioma simplex is non-elevated. The most common 
variety involving the integument of the eyelids and the sclera is the naevus 
flammeus, or port-wine mark. Vascular tumors of the lids may bleed 
either spontaneously or in response to slight trauma. The best treatment 
of nsevus vasculosus is by means of electrolysis, and even then it is prone 
to recurrence. 

If the case comes under treatment shortly after birth, painting with 
collodion may give good results. 

Lymphoma of the Eyelids (Lymphangioma).—This form of growth, 
which is rarely observed, appears as an enlargement of the eyelid, either 
alone or associated with similar growths in the orbit, the mouth, axilla, 
etc. In the eyelid a lymphoma forms an elongated sausage-shaped tumor, 
elastic and painful. The skin over the mass is often tense, shining, and 
traversed by dilated veins. The surface of the growth is slightly lobulated, 
and may be small or so large as to conceal the eyeball. Lymphoma develops 
in the course of leukemia and pseudoleukemia. Optic neuritis, retinitis, and 
retinal hemorrhages are often present in these diseases. Lymphoma of 
the eyelids may appear at any period of life, but is most frequent in middle 
age. The prognosis is unfavorable. Extirpation of the growths seems to 
be of onlv temporary value. Bronner has recorded a case which was cured 
by the prolonged internal use of arsenic. 


176 


MODERN OPHTHALMOLOGY. 


Carcinoma of the Lid (Epithelioma; Rodent Ulcer).—Cancer of the 
lid is a malignant growth consisting chiefly of epithelial cells and arising 
from mucous or cutaneous surfaces. On microscopic section it presents 
characteristic cell-formations called “nests.” While epithelioma and rodent 
ulcer present practically the same microscopic changes, their clinical feat¬ 
ures are sufficiently different to demand separate descriptions. 

Epithelioma develops most frequently from mucocutaneous junctions. 
In its earliest stage it may appear as a wart, a nodule, or a fissure. After 
a time ulceration occurs, the ulcer having indurated, everted, or under¬ 
mined edges. Sooner or later the neighboring lymphatic (pre-auricular, 



Fig. 149.—Microscopic section of an epithelioma of the eyelid. (Author.) 

(Original drawing by Dr. Carl Fisch.) 

1, Boundary between normal and epitheliomatous tissue. 2, Connective tissue. S, Small vessel. 

4, Epithelial nests. 5, Small round-cell infiltration. 

submaxillary) glands are involved. The process extends and ends in death 
by hemorrhage or exhaustion. There is little pain, of an itching or shoot¬ 
ing character, in the earlier stages of the disease. Later, when the destruc¬ 
tion of tissue is extensive, the suffering is severe. The disease occurs chiefly 
in persons past the middle period of life, and is more frequent in men than 
in women. 

Diagnosis. —Epithelioma is to be differentiated from syphilitic nodules 
and gummata, rodent ulcer, lupus, chancre, and tuberculosis. In syphilitic 
processes the progress of the disease is usually rapid and the history is that 
of infection. In gummatous ulceration there is no hardness around the 
ulcers, which are multiple and punehed-out and present an abundant puru- 






DISEASES OF THE EYELIDS. 


177 


lent discharge. In epithelioma the process is slow and the discharge scanty, 
thick, and bloody. Chancre may he differentiated by its history and rapid 
development. When there is any doubt as to the diagnosis, energetic anti¬ 
syphilitic treatment should be tried for a few weeks. Lupus presents mul¬ 
tiple lesions, which begin in childhood or youth and usually are associated 
with lupus of the nose or cheek. Lupus shows an ulcer of a saucer shape, 
with an abundant, lion-purulent discharge, free from blood, and not of¬ 
fensive. Adjoining the ulcer are numerous soft, brownish, semitrans- 
lucent tubercles. Accompanying the process is considerable inflammation, 
causing the lid to be red and swollen. The disease often begins in the 
palpebral conjunctiva and eats into the lid. It is possible, however, for 
epithelioma to be ingrafted upon lupus. Eodent ulcer is described in a 
separate paragraph. A broad, flat, slowly growing epithelioma which has 
destroyed the lid-margin and invaded the conjunctiva, which presents a 
mammillated appearance, may so closely resemble tuberculosis that only a 
microscopic examination can determine the diagnosis. 

Prognosis and Treatment. —Left to itself, epithelioma is fatal. Re¬ 
moved early, it offers a fair prognosis. If neglected until after glandular 
involvement has occurred, the prognosis is unfavorable, return of the growth 
after excision being the rule. Treatment by the Roentgen ray and by 
Finsen’s light is too recent to enable judgment to be passed as to its value. 
If neglected, epithelioma of the eyelid will extend to the eyeball and neces¬ 
sitate enucleation. In the treatment escliarotics are not to be ranked with 
excision. At the time of removal of the growth by means of the knife a 
suitable plastic operation should be made to cover the defect. 

Rodent Ulcer (Jacob’s Ulcer; Cancroid Ulcer). — This is a slowly 
growing ulcer of the face, generally involving the eyelids. Histologically 
it is a carcinoma, and is often described as a form of epithelioma. Clinic¬ 
ally it presents features which serve to distinguish it from epithelioma. 
The essential facts of rodent ulcer were described by*A. Jacob, in 1827, in 
these words: “The characteristic features of this disease are the extraordi¬ 
nary slowness of its progress; the peculiar condition of the edges and sur¬ 
face of the ulcer; the comparatively inconsiderable suffering produced by 
it; its incurable nature, unless by extirpation; and its not contaminating 
the neighboring lymphatic glands.” Jacob’s ulcer begins as a small nodule 
with depressed centre, of firm consistence and brownish-red color. After a 
variable period the skin breaks, leaving an ulcer with undermined edges 
and infiltrated border. This becomes broader and deeper, destroying all 
tissues, including the bones. It extends in the direction of the orbit, and 
often the eyeball falls out. Its etiology is obscure and the prognosis must 
be guarded. The treatment is excision. Recently the treatment by the 
Roentgen ray and Finsen's light has given encouraging results. 

Sarcoma of the Eyelid.—About fifty cases of sarcoma of the eyelid 
have been published (Yeasey). The youngest patient was seven months 
of age and the oldest seventy-six years. The size varied from that of a pin- 


MODERN OPHTHALMOLOGY. 


178 

head to that of an apple. In rare instances all four lids have been involved, 
and in 16 per cent., principally children, the disease caused death. There 
was more or less pigment in 26 per cent, of the cases. The disease returns 
in probably 50 per cent. In four cases the neoplasm was attributed to 
trauma. The symptoms are practically those of chalazion. A tumor is 
present between the skin and tarsus. It develops gradually without pain. 



Fig. 150.—-Rodent ulcer. (Grindon.) 


In the pigmented cases the discoloration will aid in the diagnosis, which 
otherwise must remain in doubt until after microscopic examination. The 
growth is encapsulated to a greater or less extent in about 14 per cent, of 
cases. The prognosis must be guarded. The treatment is excision. The 
growth may return locally or metastatically. Veasey states that 38.5 per 
cent, were spindle-cell, 38.5 per cent, round-cell, and 23 per cent, mixed- 
cell sarcomas. 










DISEASES OF THE EYELIDS. 


179 

Adenoma of the Meibomian Glands is a rare form of tumor. The 
growth involves the lids, which become nodular. Eversion of the lid shows 
yellowish, nodular masses involving the Meibomian glands. The growth 
causes the eyelid to become stiff and board-like. Knapp has reported a case 
and has found nine others in literature. The mass should be excised and 
examined microscopically. 

Noma of the Eyelids (Spontaneous Gangrene; Phagedenic Ulceration). 

—This rare condition has been observed by Rushmore, Derby, Hilbert, 
Marlow, Roger and Weill, and Morax. The disease appears in emaciated 
infants and children. It is characterized by swelling of the lid, the forma¬ 
tion of a pimple which is soon converted into a pustule and is followed by 
ulceration, and the presence of a thin conjunctival discharge. The skin, 
conjunctiva, and intervening structures soon break down, and may be partly 
or entirely destroyed. The ulcer presents sharply-defined, undermined 
edges, bordered by a zone of darkly-congested skin. There is greenish pus 
and a dirty slough. The cornea is opaque and ulcerated and perforation 
results. The ulceration may spread into the eyebrow and on to the cheek. 
The bacterial cause of noma has not been determined. The prognosis in 
these cases will depend on the time when the patient is brought for treat¬ 
ment and on the general condition. Cleansing and antiseptic treatment will 
be in order locally, and supportive measures internally. In Marlow’s case 
Labarraque’s solution was used with benefit. The administration of diph¬ 
theria antitoxin has been strongly recommended. 

Colloid Degeneration of the Skin, a rare disease of which five authentic 
cases are on record, involves at times the forehead, bridge of the nose, eye¬ 
lids, and, in some instances, the conjunctiva. The diagnosis can be made 
only by a competent dermatologist. 

Hyperidrosis, or excessive sweating, is noted in connection with the 
disease occurring on the face and body. It may he confined to the lids of 
one eye when there is unilateral facial hyperidrosis. In this case it indi¬ 
cates an irritation or lesion of the sympathetic nerve. 

Chromidrosis, or colored sweat, is occasionally observed affecting the 
eyelids, and may he either yellow, red, or blue. It may be that only one- 
half of the lids is affected, and when this occurs it is the outer half. The 
majority of these patients are women. In hysterical subjects the disease is 
often simulated, ordinary coloring substances—such as indigo, soot, and 
plumbago—being used to carry out the deception. 

Pliosphoridrosis and Uridrosis, or phosphorescent and urinous sweat, 
are seen about the eyelids and always in connection with a generalized form 
of the diseases, which depend upon a general involvement of the system. 

Sudamina, which consists of pinpoint- to pinhead- sized vesicles, usu¬ 
ally occurring upon the hands, is also rarely observed upon the eyelids. 
It is caused by a too rapid formation of sweat, and is observed in summer. 
The application twice a day of a 1-per-cent, strength solution of chromic 
acid will rapidly cause its disappearance. 


180 


MODERN OPHTHALMOLOGY. 


The disorders of secretion of the cutaneous glands of the skin, which 
are most frequently seen, embrace those of the sebaceous and of the sweat- 
glands. 

Seborrhea is observed at times upon the upper eyelid in the dry form 
and on both lids in the oily form. Here it is not only necessary to use 
internal treatment, but local applications, preferably in the form of sulphur 
ointment or a mixture of equal parts of 5-per-cent, oleate of mercury and 
precipitated sulphur, mixed with a base of cold cream (unguentum aquae 
rosse). 

Miliaria, or lichen tropicus, better known as “prickly heat,” is a 
common affection of the eyelids in summer. It is easily recognized, and 
occurs most frequently in fat babies. In these a mild conjunctivitis is a 
very common accompaniment. An efficient as well as rapid treatment of 
the skin eruption is by the application, three or four times daily, of a mild 
solution of sulphate of copper (gr. x to §vj of water). 

Milium is perhaps at times a retention cyst of the sebaceous glands. 
Recent investigation has shown that the small tumor is an agglomeration 
of the prickle layer of the epidermis which has become snared off into the 
corium during embryonic life. It is often observed, chiefly about the lower 
eyelid, but often on the upper one also. While occasionally congenital, it 
is usually not observed until after puberty. Milia may occur sparsely or 
may be thickly studded over the affected area. The lower lid is more often 
affected than the upper one, and the tendency of the distribution of the 
lesions is said to be rather toward the outer canthus. When occurring in 
patches, the disease may resemble xanthoma. The treatment is simple, 
consisting in the enucleation of every milium with a milium needle, at the 
same time destroying the lining membrane of the little cyst to prevent the 
condition from recurring. 

Acne Rosacea occurs about the eyelids in severe cases and is inclined 
to be chronic in this locality, as the lids are not only congested, but involved 
in a certain degree of chemosis. The diagnosis is rendered easy by the 
presence of the trouble in the face. Lotions are to be avoided, as they are 
apt to produce irritation of the conjunctiva. Ointments containing from 15 
to 30 grains of sulphur to the ounce of simple cerate, applied twice daily, 
will act favorably. 

Asteatosis, or the lack of secretion of sebum, requires particular atten¬ 
tion, as its pronounced stage will produce ectropion. Here the regular 
application of animal fats and the internal administration of arsenic will 
procure the best results. Little hope of permanent recovery can be held out. 

Steatoma, which is supposed to belong to the class of dermoids, is not 
infrequently seen about the lids. As a rule, there is but one, and most 
usually it is about the outer canthus of the upper or lower lid. The growth 
of these cysts is slow; and they are due to some injury to the opening of 
the sebaceous gland. The tumor is round and smooth and varies from the 
size of a pinhead to that of a hazelnut. It contains broken-down epithelial 


I 


FLUTE VII, 


External Diseases ef the Eye : 



. VjlSnj” i, O 

Fig, 1, Fig. 2. 

Distichiasis and Trichiasis. Chalazion. 


Fig, 3. 

Blspharitis Marginalis. 


Fig. 4. 

Symblepharou. 


1 XM> 


Fig. 5 , 
Ectropion. 




1 ■} 


Fig. B. 

Entropion, 



Fig, 7. 

Chancre of the Conjunctiva 
(He Schwainitz,) 


Fig, a, 

Epithelioma of the Corneoscleral 
Region, (diver.) 
















I 


180 

The dr- 
are most i: < 


Sew-. 
and ' 
inn 

C ■, ■ ' i 


U¥ r*T;-ui c I. 

3Y<3' bjU Id SBfcf33slCI I nutate 3 


-S .gift 
.xiD^SBis rfD 


vf tin' skin, which 
nit ■ of the sweat- 


; • i the dry form 
>t ■•<-;-oary to use 

!’ ••• yt .grr'ie form of sulphur 
^(SWta^.jboa ar d 

•f (ere m (vingmentum aquae 


.* .at"* 

jtoraiiqBltfijnrS 


a .firi . 

motqaalaac 


con j 

$s 

to Ik? v 

in .i c 
prnfs'-ruv in 

;'i , ■ 

to 30 gnu :■ 
will act ikf"'' 

■ A steatosis, 
lion, as its i ' 
application. af twit ■ ■ 

OMM'-r.rv i fr. 10 I' 1 ” 1 

lEisIaacanocD nai to sainlieiiJicia. 
Stf^a'VHO) .uc’bhix 

••u,;ucnt)y seen d 
TP, p is about the < 

■ i s' ■ <'\ sfcs is low - a:* 

■ < v ■-. •*'.!• ’ oj.■» gland. 'I 

■ • •; .- oinbcad to that of a 


Ina". i) as ‘‘prickly heat/’ is a 
/. • tnnuer It is easily recognized, and 
in th< •<> a wild conjunctivitis is a 
:. ■ iii n ji r». Ticiem as well as rapid treatment of 

• -n, th; ;• or '‘out tiirn s daily of a mild 
;;npp' - fco.jvj of water). . 

- at tin • a retention cyst of the sebaceous glands. 

'■ ; ~ -' 1 ' 1 ■ • ; i. t;" m.\nKM u.& v&k' 10rr ' ( ‘ on 

the •••pjdettnis which has become s-nm. it off into the 
• ii : . . it U often observed, chiefly ah- >i d lower 
> per one i occa 

; aril after pc wiy. iM ilia nay oecusparsely or 
vcy the affect' d area. The Jowm iid is more often 
•ne and' the tendency- of the hr-! ition of the 
toward the outer cam!ms. Vf * • i 

••emble xanthtwha; The Ireatm---. ..pm, 
i ■■■: of: every milium with a milium needle, at the 
\V~ T ' .*• membra- ■ of the ( g! it to . mi the 

jsoiijD'u-oa: 

he eyelids in sever* case- nod is inclined 
lids urn not only congested, but involved 
•'be diagnosis is rendered easy by the 
■it Lotions are to be avoided, as- they are 

'•'diva. Ointments containing.from 15 
c.f simple cerate, applied twice daily, 


'bum, requir i- particuiai atten- 

■v ectropion. Here the regular 

u: : administration of arsenic will 

: Client-^111 o’.'t 

.aTrUoni»tooq rx*j lo/sip^Briq . 

(. shuia \/> >ia 2' e U) 1 '' 1 " ' ' 

■ ■ : - >..!! o,i. on,] i'nosf 

• or lower lid. The growth 
•.jar- V i"• ■ • perdu _ of 
mooth and vjj t - e from the 
•t >;hi* broken-down epithelial 


PLATE 7 





DISEASES OE THE EYELIDS. 


1S1 


cells, forming a pultaceons mass. These tumors have • well-defined walls. 
They occur in children as well as in adults. The treatment is to incise the 
tumor, empty it of its contents, and tear out the lining sac. A rapid recov¬ 
ery follows, and a well-done operation in a few days shows no-sign of having 
been performed. 

Chalazion (Meibomian Cyst; Tarsal Tumor; Hailstone) is a tumor 
of the eyelid which is generally described as a Meibomian cyst. It is not 
directly a cyst, but a mass of granulation tissue scantily supplied with ves¬ 
sels and tending to necrosis. The cyst develops only secondarily by the 
breaking down of granulation tissue. The tumor starts primarily, not from 
glandular tissue, but from infection, and is due frequently to the tubercle 
bacillus. Histologically a chalazion is composed of typical tuberculous tis- 



5 


o 


o 


Fig. 151.-—Microscopic section of a chalazion. (Author.) 

(Original drawing by Du. Carl Fisch.) 

1, Meibomian gland cut across. 2, 2, Areas of round-cell infiltration. 3, Artery. 4, Conjunctival 
epithelium. 5, Giant cell. 6, Epithelioid cell. 

sue, presenting numerous round cells, epithelioid cells, and occasionally a 
giant cell (Fig. 151). Recently Hala examined twelve cases of chalazion 
histologically and bacteriologically and constantly foimd a bacillus identical 
with the xerosis bacillus. He believes that these bacilli, which often are 
found normally in the conjunctival sac, are rubbed into the tissues, where 
they produce chalazia. Fisch, of St. Louis, has demonstrated the presence 
of tubercle bacilli in giant cells found in chalazia. 

Symptoms. —A chalazion forms a round, hard, small tumor situated 
commonly in the middle of the lid near its border. It is more frequent 
in the upper than in the lower lid, and is more often found in adults than 
in children. Its progress may be in the direction of the conjunctiva (in¬ 
ternal chalazion) or toward the skin (external chalazion). When the lid 






182 


MODERN OPHTHALMOLOGY. 


is everted the conjunctiva over the chalazion is found to be red and thick¬ 
ened, and in advanced cases a bluish or grayish spot is seen corresponding 
to the thinned tarsus. Several chalazia may be present at the same period 
or single tumors may develop from time to time. As a rule, chalazion is 
painless, and causes inconvenience only when it attains a considerable size, 
in which case the eyelid may droop and the tumor will cause a deformity. 
Xot infrequently chalazia disappear spontaneously. When perforating the 
conjunctiva, the chalazion leaves granulations and thus may simulate a 
malignant growth. The growth of a chalazion, while generally slow, may 
be rapid. Acute chalazion may develop rapidly, with pain, swelling, and 
localized conjunctivitis. The growth may undergo suppuration, in which 
case it resembles a stye. 

Etiology.— Chalazion is due to infection. It is aggravated by errors 
of refraction and by conjunctivitis. At least 20 per cent, of individuals 
with chalazion suffer with tuberculosis; in 70 per cent, conjunctivitis and 
blepharitis are present; in 30 per cent, there is lacrimal stricture; 27 per 
cent, are ametropic, and 12 per cent, have scrofula (Strzeminski). 

Diagnosis. —Acute chalazion is to be differentiated from hordeolum 
by the diffuse appearance of the latter. The “pointing” of hordeolum is 
noticeable. Chronic chalazia may be mistaken for sebaceous cysts. Here 
the firm attachment of the chalazion to the tarsus will clear the diagnosis. 
Sarcoma of the eyelid may so closely resemble chalazion that the diagnosis 
can be made at an early stage only by microscopic examination. Recur¬ 
rence of a lid tumor soon after removal will cause suspicion of malignancy. 

Treatment. —Acute chalazion should be treated by incision and the 
frequent application of hot compresses. Chronic chalazion may sometimes 
be cured by the daily use of massage and the application of mercurial or 
iodin ointments. The iodid of cadmium is recommended because of not 
staining the skin. If, after several weeks’ trial, this plan of treatment fails, 
the case will call for surgical intervention as described elsewhere in this 
chapter. In cases of recurring chalazia it will be necessary to give careful 
attention to the general health and to the correction of errors of refraction. 

Alopecia and Alopecia Areata, or progressive baldness and baldness 
in spots, are observed to affect the eyebrows. Local stimulating applications 
and appropriate general treatment will be found to be the most efficient 
means to jirocure good results. Hysterical alopecia of the lids is sometimes 
seen in neurotic females and in hysterical children of both sexes. Such 
subjects systematically pull out the cilia. 

Parasitic Skin Diseases are very rarely observed upon the eyelids, that 
which is most ordinarily seen being due to the pediculus pubis. These 
pediculi are occasionally found to infest the eyelashes of infants, and in 
consequence to produce tinea, leading to acute conjunctivitis and blepharitis 
(phtheiriasis; blepharitis pediculosa). The treatment consists in picking 
off the pediculi and applying a soothing lotion to the affected eye. 

Mosquitoes, fleas, and bedbugs occasionally attack the eyelids of sleeping 


DISEASES OF THE EYELIDS. 


183 


persons and produce lesions. These may be small red papules with a scarlet 
central point or wheals, and should he treated by means of a soothing 
ointment. The parasite must be looked for and removed. 

Eavus of the Eyelids is an exceedingly rare disease, only five cases 
having been reported. The disease first shows itself as yellowish-red ves¬ 
icles, which are painful. Later there is a dry, fissured crust, elevated above 
the level of the surrounding skin. The crust is of a sulphur-yellow color, 
and its centre shows a depression, with a variety of colors varying from 
white to sepia brown. Microscopic examination shows the presence of the 
sporidia and mycelia of achorion Schoenleinii. The treatment consists in 
the use of an oiled compress in the evening and frequent washings with 
bichlorid solution (1 to 4000). 

Cysticercus of the Eyelid is an exceedingly uncommon affection. It 
may involve either eyelid or may be found beneath the skin of the eyebrow. 



Fig. 152.— Varioloid of the eyelids. (Vox Ammon.) 
The patient had suffered a previous enucleation. 


It develops without inflammatory symptoms, and forms a round, elastic, 
movable tumor which is likely to be mistaken for an ordinary cyst. Opera¬ 
tion will show its true character. 

Variola manifests itself on the eyelids in the papular, vesicular, and 
pustular stages. The integument becomes swollen and edematous as well 
as bright red in color. A more or less marked conjunctivitis shows itself, 
and it is sufficiently severe to cause the escape of an appreciable quantity 
of muco-purulent secretion. The eyelids themselves burn and itch. Efforts 
to relieve this by rubbing with the fingers will produce inoculation of non- 
affected parts of the skin and of the conjunctiva. An efficient means of 
treating the itching is by the use of red rays, which not only alleviate this 
.symptom, but prevent subsequent pitting. In any event, the further devel¬ 
opment of pus must be arrested. This is to be done by applications and 
instillations of efficient antiseptics. The eruption, although not commonly 









184 


MODERN OPHTHALMOLOGY. 


severe on the lids, being usually discrete in its distribution, at times is 
aggregate and even confluent. 

Vaccinia of the Eyelid is rarely observed. The virus is carried by the 
fingers to the margin of the lid, where it causes an ulcer. Pain, swelling, 
and redness of the lid, conjunctivitis, and tenderness and enlargement of 
the pre-auricular and submaxillary glands are present. There is generally 
some fever and malaise. The condition is readily differentiated from syph¬ 
ilis by the history of the case. In about a week crusts fall from the lid, the 
ulcer heals, and recovery is complete. Aside from cleanliness, these cases 
require no treatment. 

Varicella is not frequently seen to manifest itself in the eyelids. When 
it does, it is not severe in character, perhaps only one lesion being found. 
The subjective symptoms are practically nil. There is little, if any, itching 
until after a crust forms. Patients will invariably make attempts to remove 
this, leaving a marked and comparatively deep pit. The scar is marked, 
but on account of the scarcity of lesions it produces only slight deformity. 
The treatment of the disease is purely symptomatic. 

Scarlatina manifests itself about the eyes in the form of a catarrhal 
conjunctivitis, accompanied by a more or less severe chemosis. The eye¬ 
lids are of a scarlet color, more or less marked edema exists, and an intense 
sense of burning is present. The edema is so severe in some cases that the 
patient is unable to open the eyes. It is likely to be mistaken for erysipelas 
by those who do not carefully observe the other symptoms present. When 
the stage of desquamation has been reached, large, thin scales will separate 
from the eyelids. Care should be taken that these are not torn off. Mild 
astringent ointments should be used in this stage, whereas cooling lotions 
are indicated in the acute stage of the disease. The conjunctivitis should 
be treated appropriately. 

Rubeola, or measles, also attacks the eyes in a manner similar to scar¬ 
latina. In this case the eyelids present the characteristic splotches observed 
upon other parts of the skin. The conjunctival inflammation is distinctly 
catarrhal. The involvement of the lids and conjunctiva is of a mild type, 
and is to be controlled by the use of sedative and mild astringent lotions. 
When desquamation begins a neutral ointment should be applied. 

Blepharochalasis, a relaxation of the palpebral skin, has been described 
by Fuchs, Hotz, Starkey, and others. Following recurrent angioneurotic 
edema, the skin loses its attachment to the tarsus, so that, when the eyelid 
is raised and slides over the eyeball, the skin is not retracted with it, but 
falls over the retracting eyelid. The condition can be cured by excising 
a portion of redundant skin and anchoring the palpebral skin to the tarsus. 

Emphysema of the Eyelids.—A collection of air in the cellular tissue 
of the eyelids not infrequently follows a compound fracture of the nasal 
bones or an operation upon the lacrimal canal. In either case, the patient, 
by blowing the nose, forces air into the cellular tissue. There is pain, 
sudden and great swelling of the lid, and air-tumefaction. Palpation gives 


DISEASES OF THE EYELIDS. 


185 


a sense of crepitation and a peculiar soft feeling like that of a feather bed. 
The air comes from one or more of the adjacent cavities: the nasal fossa, 
ethmoidal cavity, frontal sinus, or antrum of Highmore. Emphysema may 
follow the operation of opening the ethmoid cells. Douglass has recorded 
cases in which emphysema of the upper lid followed an attempt to blow 
secretions from the nose, in patients who had suffered no operation or 
trauma. In these cases there was probably a pathologic opening between 
the ethmoid cells and the orbit. The prognosis of emphysema is favorable. 
A compress bandage should he applied. 

Blepharitis Marginalis (Blepharitis; Ophthalmia Tarsi; Tinea Tarsi; 
Seborrhea of the Palpebral Margins; Blepharitis Ciliaris; Blepharitis 
Ulcerosa; Psorophthalmia; Sycosis Tarsi; Blepharo-adenitis). — These 
terms are applied to several varieties of chronic inflammation involving the 
margins of the eyelids (Fig. 3, Plate VII). 

Hyperemia of the Lid-margins is present in persons who do an 
excessive amount of work at near points (writers, watchmakers, sewing- 
women) or follow their vocations in a vitiated atmosphere or under un¬ 
favorable illumination. It is common in persons with errors of refraction 
and in those who are addicted to the use of alcohol and tobacco. When, 
in addition to hyperemia, small scales form on the lid-margins, the con¬ 
dition is known as blepharitis squamosa. If the lid-border becomes covered 
with yellow crusts, which, when removed, leave ulcerated areas, the disease 
is known as blepharitis ulcerosa or eczematosa. 

1. In Blepharitis Squamosa (seborrhea of the lid-border; blepharitis 
ciliaris) the lid-margin is reddened, the palpebral conjunctiva is hyperemic, 
and the space between the cilia is filled with small, thin, whitish scales 
resembling dandruff. The scales can be removed imperfectly by washing, 
or thoroughly with the forceps, leaving the lid-margin reddened and suc¬ 
culent, but not ulcerated. The cilia fall out easily. They soon grow again. 
Instead of the scaly formation mentioned, the lid-margins may present 
yellow crusts, with no underlying ulceration, due to the drying of excessive 
sebaceous secretion. Patients with blepharitis complain of a burning or 
itching sensation. Generally there is also present a chronic type of catar¬ 
rhal conjunctivitis, with a slight formation of mucus, which may at times 
spread over the cornea and cause momentary blurring of vision. The eyes 
are sensitive to light, heat, and dust. They tire easily and styes often are 
present. 

2. Blepharitis Ulcerosa. —This is a more severe process. The lashes 
are matted together with yellow crusts. On their removal a raw bleeding 
surface remains. From the centre of each yellow elevation a cilium arises. 
The lid presents numerous abscesses from suppuration in the hair-follicles 
and their sebaceous glands. It shows an irregular, worm-eaten condition 
from the cicatrices of healed abscesses and the extension of those yet exist¬ 
ing. Where the cicatrices exist, the cilia are absent because of destruction 
of their follicles. When blepharitis ulcerosa has existed for a long time. 


186 


MODERN OPHTHALMOLOGY. 


few cilia remain, and those present are often .found in small tufts glued 
together with dried secretion. This form of lid inflammation is much more 
serious in its sequelae and prolonged in its course than the squamous 
variety. The sequelae are chronic catarrhal conjunctivitis, destruction of 
the cilia (madarosis), trichiasis, hypertrophy of the lid-margin, which 
becomes rounded and bordered with fleshy-looking conjunctiva (tylosis), 
ectrojnon, persistent lacrimation from eversion of the puncta, blepharo¬ 
spasm, photophobia, and eczema of the face. These conditions react upon 
the blepharitis, thus establishing a vicious circle. 'When, in an old case of 
blepharitis ulcerosa the “lid-border becomes smooth, red, glazed, everted, 
thickened, weeping, and destitute of lashes,” the term lippitudo is applied. 

Etiology and Pathology. — Blepharitis marginalis is a common 
disease among children and scrofulous subjects. It is particularly frequent 
in blondes. Seborrhea of the lid-margin may follow in the wake of a similar 
disease in the hairy scalp. Eczema of the lid-margins is generally asso¬ 
ciated with eczema of the scalp, ear, and face. Uncorrected or improperly 
corrected errors of refraction certainly increase the local trouble, if indeed 
they do not cause it. Often blepharitis follows one of the exanthematous 
diseases of childhood. It is frequently associated with naso-pharyngeal 
disease and with stenosis of the lacrimo-nasal duct. Staphylococci are 
found in the eczematous form of blepharitis. A minute parasite inhabiting 
the sebaceous follicles, demodex folliculorum, is regarded as a cause; and 
a vegetable growth, the trichophyton fungus has been observed in some 
cases. The etiologic importance of the demodex folliculorum is doubted 
by Sulzer, who found it in the normal lids of one person in six examined. 
Kaehlmann has applied the term blepharitis acarica to those cases in which 
this parasite has been found. 

From what has been stated it is evident that the pathologic changes 
in this disease concern chiefly the glands and cilia in the simple forms, 
and in addition thereto the adjacent structures are involved in the ulcerous 
form. 

Diagnosis. —Blepharitis may be confounded with conjunctivitis. If, 
after removal of crusts, the skin of the lid-margin is normal, the case is 
one of conjunctivitis. In blepharitis this area is either reddened or red¬ 
dened and ulcerated. In phtheiriasis of the lids the lid-borders look dark 
from the presence of the nits of crab-lice on the lashes. Careful examina¬ 
tion under a magnifying glass will clear the diagnosis. This affection, 
which itself sometimes causes blepharitis, is found almost exclusively in 
children. 

Prognosis.— Blepharitis squamosa offers a favorable prognosis. The 
eczematous form is somewhat rebellious to treatment. Either form may 
persist for months or years, yet the majority will be cured. For madarosis 
there is no efficient treatment. 

Treatment. —Many patients with blepharitis require tonic treatment. 
Attention should be given to the condition of the alimentary tract and the 


DISEASES OF THE EYELIDS. 


187 


nasopharynx. The proper correction of errors of refraction or of muscle 
imbalance is of great importance. As regards local treatment, the two 
main requirements are: (1) to keep the lid-margins clean and (2) to 
apply appropriate and soothing remedies. The first object can be attained 
by the daily removal of scales and dried secretion by means of forceps. 
This should be done by the surgeon himself. If, after thorough cleansing 
of the lid-margin, there remains a reddened and succulent area without 
ulceration, an ointment of ammoniated mercury or yellow oxid (gr. i or 
ij to 5j) should be rubbed into the roots of the cilia. Persistent local 
treatment, together with attention to the general health and the wearing 
of proper glasses, will give favorable results in this, the squamous form of 
blepharitis. 

In the eczematous form of the disease removal of the dried crusts will 
expose areas of ulceration. There will be free bleeding and some pain con¬ 
nected with the thorough removal of the crusts. After cleansing with 
peroxid of hydrogen, each ulcer should be touched with a strong solution 
of silver nitrate or with the mitigated stick. The resulting scab should not 
be disturbed. After it has dropped off, the lid-margin is to be cleared of 
all debris, and any bleeding points remaining are treated similarly. Each 
day the ointment of ammoniated mercury or the yellow-oxid ointment 
should be applied to the lid-margins. After the ulcers have healed the 
surgeon should examine for errors of refraction and properly correct them. 

Conjunctivitis, lacrimal stenosis, entropion, ectropion, and naso¬ 
pharyngeal disease, which may be present, should be given appropriate 
treatment. 

Among other remedies for blepharitis are the oils of cade, rue, or 
juniper; creolin ointment, Hebra’s compound diachylon ointment, boric- 
acid ointment, solution of formalin, sulphur ointment, pyrogallol salve, 
and solution of chloral hydrate. 


OTHER DISEASES OF THE EYELIDS. 

Lagophthalmos (Hare's Eye).—This term, derived from the ancient 
belief that the hare sleeps with open eyes, is applied to cases in which, 
.owing to drooping of the lower eyelid, there is inability to close one or 
both eyes. Attempts to close the lids cause the globe to roll inward and 
upward, the lids remaining open. The cornea* being exposed, becomes dry; 
dust and foreign bodies lodge upon it; the tears, owing to paralysis of 
Horner’s muscle, no longer pass into the tear-ducts, but flow on to the 
cheek; and soon a corneal ulcer forms which may end in perforation and 
loss of the globe. The lesion may be lagophthalmic keratitis or xerosis of 
the cornea (see chapter on the cornea). The condition may be attributed 
to: (1) paresis or paralysis of the facial nerve; (2) spasm of the upper 
eyelid, due to disease of the third nerve; (3) shortening of the lids; (4) 
extreme proptosis, due to exophthalmic goitre or the growth of orbital 


188 


MODERN OPHTHALMOLOGY. 


tumors; (5) enlargement of the globe, as in hydrophthalmos; (6) severe 
and exhausting diseases in which the sensitiveness of the cornea is lost 
and the winking reflex is absent. Cases of lagophthalmos are usually clas¬ 
sified as paralytic and non-paralytic. 

In lagophthalmos from disease of the facial nerve, the central lesion 
may be cortical, intracerebral, or nuclear. In the peripheral form the 
lesion may involve the seventh nerve within the temporal bone, in the canal 
of Fallopius (intracranial), or after its escape from the stylo-mastoid 
foramen (extracranial). Cortical facial paralysis is seen following in¬ 
juries, tumors, abscesses, and localized inflammations of the motor centres. 
Intracerebral cases result from syphilis of the vessels or hemorrhage. The 
nuclear form, originating in the pons, is found in Duchenne's disease and 
in some cases of tabes. These three forms usually present normal electrical 
excitability and the retention of ability to use the occipito-frontalis and 
orbicularis palpebrarum muscles. On the contrary, when the lesion is within 
the bone or beyond it, all three divisions of the facial are equally involved. 
Hence the presence of lagophthalmos is a valuable diagnostic sign. Injury 
to the facial nerve in the aqueduct of Fallopius is not an uncommon sequel 
to middle-ear suppuration. The site of the lesion can be determined by 
the presence or absence of such symptoms as paralysis of the soft palate, 
diminution or abnormal acuteness of hearing, diminution in the saliva, or 
alterations in taste. Beyond the stylo-mastoid foramen the nerve can 
suffer from injuries either accidental or surgical, the growth of tumors or 
enlarged glands, and certain indefinite causes, attributed to taking cold. 
It is evident that the prognosis of paralytic lagophthalmos must be much 
more unfavorable if the lesion be central than if peripheral. Usually the 
so-called rheumatic facial paralysis lasts only a few weeks. The electrical 
condition of the affected muscles will furnish valuable data. If there is 
no change in their reaction to either electric current, the prognosis will 
be favorable; if the “reaction of degeneration” is found, recovery will be 
slow; if secondary contractures and twitchings supervene, the recovery will 
either be very slow or will never occur (Ramsay). 

Cases in which lagophthalmos is a symptom of disease of the third 
nerve are of rare occurrence. Shortening of the eyelids leads to exposure 
of the globe and, when congenital, is named congenital lagophthalmos. 
When acquired it may be produced by laceration of tissue, burns or scalds, 
necrosis of the osseous or gangrene of the soft tissues, etc. 

Treatment. —This will vary according to the cause. The conjunc¬ 
tiva should be kept clean by frequent instillations of a solution of boric acid. 
In exhausting diseases the lids should be kept closed by adhesive plaster or 
bandages. In severe cases of lagophthalmos, where the cause is irremedi¬ 
able, the operation of uniting the lids (tarsorrhaphy) should be performed. 
This unites the lids, shortens the palpebral fissure, and protects the cornea. 

Blepharophimosis, a narrowing of the palpebral openings, is found in 
congenital and acquired forms. The former is rare; the latter compara- 


DISEASES OF THE EYELIDS. 


189 


tively frequent, being caused by trachoma. In unusual cases it is due to 
loss of tissue and consequent contraction at the outer canthus. It is prop¬ 
erly treated by canthotomy. 

Blepharospasm, a tonic or clonic spasm of the orbicularis palpebrarum 
muscle, firmly closing the lids, is a common symptom in conjunctival and 
corneal injuries and diseases (symptomatic blepharospasm). It not infre¬ 
quently occurs without known pathologic condition (essential blepharo¬ 
spasm). In the tonic form the lids close spasmodically and remain closed 
‘ for a time; in the clonic form the spasm is of short duration, is immediately 
followed by relaxation, and this in turn is followed by another spasm. A 
common form of blepharospasm is the fibrillary contractions, which are 
often alarming to the patient. The twitching of the fibres can be seen 
near the lid-margin. It indicates a local irritation, such as often is found 
in mild conjunctivitis or in errors of refraction, but often is without sig¬ 
nificance. It is frequent in habit chorea and hysteria. These clonic con¬ 
ditions are of momentary duration. In some cases clonic blepharospasm 
is a distressing affection, particularly in aged subjects. The contractions 
are frequent and violent, involving not only the orbicularis, but also the 
adjacent facial and temporal muscles. This form is often rebellious to 
treatment. Hysteric blepharospasm is often seen in neurotic females up 
to the middle period of life. Yon Graefe described cases of spasm of the 
orbicularis occurring in persons who had been subject to trigeminal neu¬ 
ralgia, the supra-orbital and supramaxillary branches being often involved. 
The tonic contraction in these cases can be controlled temporarily by 
pressure over the nerve-branches or permanently by subcutaneous section 
of the trunk. Similar cases and results are seen in persons who have never 
been subject to neuralgia. By far the most frequent class of cases is that 
in which the spasmodic action follows irritation or inflammation of the 
conjunctiva, lid-margin, or cornea (reflex blepharospasm). It is present 
in practically all cases of phlyctenular conjunctivitis and keratitis and 
often persists long after the subsidence of the acute conjunctival or corneal 
symptoms. In such cases careful examination will show the presence of 
a minute fissure located more often at the outer than at the inner canthus. 
The patient with reflex blepharospasm shuts the eyelids tightly, strenu¬ 
ously resists efforts to open them, hides the head in a handkerchief or 
pillow, and dreads exposure to light. 

A rare and obscure form of disease is that in which persistent tonic 
blepharospasm occurs. When finally the eyes are opened, there may be 
temporary loss of vision without fundus changes, or great reduction in 
visual acuity with marked retinal, chorioidal, or optic-nerve lesions. 

Treatment. —In all cases of acute blepharospasm search is to be made 
for the cause, which, if possible, is to be removed. Blepharitis marginalis, 
follicular conjunctivitis, phlyctenular keratitis, fissure of the .canthus, 
ametropia, insufficiency of the external ocular muscles, carious teeth, nasal 
and pharyngeal lesions, anemia, and chlorosis are among the conditions 


190 


MODERN OPHTHALMOLOGY. 


frequently found. Appropriate local treatment, together with the internal 
use of arsenical and ferruginous preparations, will generally bring about 
a cure. The ancient and barbarous method of seizing the child by the 
heels and immersing the head in cold water, in order to overcome blepharo¬ 
spasm, is no longer practiced. In rebellious cases of fissure the lids are to 
be stretched, the hssure cauterized with solid stick of nitrate of silver, and 
the ointment of yellow oxid or ammoniated mercury applied. This severe 
treatment should be followed by cure, provided the conjunctival and cor¬ 
neal affections are properly treated. In all cases of spasm search is to be 
made for foreign bodies in the fornices and cornea. Hysteric blepharo¬ 
spasm is best treated by suggestion. In senile blepharospasm treatment will 
likely be beneficial if pressure-points can be found. Hypodermic injections 
of morphin or cocain, the use of the galvanic current, or the application 
of veratrin ointment are suitable remedies. Large doses of the fluid 
extracts of conium and gelsemium may give relief. Stretching of the 
trunk of the facial nerve, while sometimes successful, is generally without 
permanent value. 

Trichiasis and Distichiasis.—In these conditions (Fig. 1, Plate VII) 
the cilia are turned inward and rub against the globe. In trichiasis the 
lashes turn inward without inversion (entropion) of the lid, the condition 
being the result of long-continued blepharitis or trachoma. In entropion 
the lid-margin is inverted, the tarsal plate being deformed. The term dis¬ 
tichiasis is applied to a condition in which supernumerary cilia are present. 
Commonly the cilia are present in two rows, one of which is directed nor¬ 
mally, the other being turned backward and rubbing the globe. Often 
small white hairs, best discovered by the aid of oblique illumination or by 
the use of the binocular magnifier, are found along the lid-margin or in the 
inner canthus. When directed toward the globe or toward the caruncle they 
cause a persistent conjunctivitis. 

The rubbing of the cilia against the e} r eball causes a constant sensation 
of sand or foreign body, and leads to redness, lacrimation, conjunctival 
discharge, and vascular keratitis. Under the circumstances, it is useless 
to expect benefit from remedies applied to the conjunctiva or cornea until 
after the source of irritation has been removed. 

Treatment. —If the misplaced cilia are few in number, they should 
be pulled from time to time until the patient is willing to submit to opera¬ 
tive intervention. The conditions mentioned above can be relieved bv 

%/ 

electrolysis: a sure, but painful and tedious, method. When numerous 
cilia are misdirected, a suitable operation should he performed. 

Symblepharon is described in the chapter on diseases of the con¬ 
junctiva. 

Ankyloblepharon, adhesion of the eyelids along the palpebral margin, 
may be partial or total. It results from the growing together of two raw 
surfaces. It is rarely congenital. As an acquired affection it follows 
ulcerations, burns, and other injuries. It is sometimes observed after 


DISEASES OF THE EYELIDS. 


191 


croupous conjunctivitis. Ankyloblepharon may exist alone, but more fre¬ 
quently symblepharon also is present. The prognosis is favorable in un¬ 
complicated ankyloblepharon, an operation (cutting the adhesions) serving 
to restore the palpebral opening. When associated with symblepharon the 
case will require also one of the symblepharon operations. 

Ptosis (Blepharoptosis), a drooping of the upper eyelid, may be partial 
or complete, unilateral or bilateral, congenital, hereditary, or acquired. 
In the higher degrees it interfere, with vision, the lid covering the cornea. 
In bilateral cases the patient will throw the head far back to gain better 
vision. At the same time the occipito-frontalis muscle is brought into play. 
Thus a picture is presented which is characteristic. In true ptosis the 
levator of the upper lid is either congenitally absent, injured, or its nerve- 
supply—a branch of the third nerve—is interfered with. Spurious ptosis 
is seen in patients with tumors and inflammations of the upper lid. Uni¬ 
lateral ptosis, dating from birth, may be due to injuries during instru¬ 
mental delivery. There are interesting cases of unilateral ptosis in which, 
while the eye cannot be opened by the strongest effort of the will, it will 
immediately open with the opening of the mouth. Thus there is associated 
action of the levator and pterygoid muscles. In other cases the upper lid 
can be raised only when the eye is adducted or abducted. Paralytic ptosis 
may exist alone or in association with paralysis of the other ocular nerves, 
notably the fourth and sixth nerves. It is a part of the symptom-complex 
of the rare disease known as recurrent oculomotor paralysis (ophthalmic 
migraine of Charcot). It is a striking symptom in ophthalmoplegia externa 
or chronic nuclear palsy. It may be a symptom of disease in the cerebral 
hemisphere. According to Swanzy, it is often the result of a cortical lesion. 
Steffen saw a case of double ptosis due to tubercular degeneration of the 
corpora quadrigemina. It is found sometimes in crossed hemiplegia, the 
lesion being intrapeduncular. Ptosis is common in hysteria and congenital 
ataxia. 

Anemic women, at or about the menopause, are subject to a form 
of the disease, which, from its generally appearing upon awakening from 
a long sleep, is known as matinal ptosis. Slight degrees of ptosis are found 
in paralysis of Muller’s muscle from disease or injury of the sympathetic 
nerve or from the intentional removal of the superior cervical sympathetic 
ganglion. In these cases miosis, unilateral sweating, and diminished intra¬ 
ocular tension are prominent symptoms. Eamsay has recorded a case of 
reflex ptosis in which a cure speedily followed the extraction of a decayed 
molar tooth. In elderly persons slight ptosis is sometimes associated with 
uncorrected presbyopia. 

Treatment. —Every case of ptosis should be studied carefully to 
determine its cause. Antisyphilitic or antirheumatic remedies will cure 
many cases. Electrical treatment is of some value. After these measures 
have failed and the condition is of long standing, one of the operations 
described elsewhere in this chapter should be performed. 


192 


MODERN OPHTHALMOLOGY. 


Ectropion is an eversion of the eyelid. This, of course, exposes the 
conjunctiva. The condition (Fig. 5, Plate VII), which may be partial or 
complete, has been classified by Czermak as follows :— 

1. Ectropion from traction on the anterior part of the lid: (a) cica¬ 
tricial ectropion, and (b) ectropion from division of the lid by a wound 
vertical or oblique to the musculature (the so-called wound-coloboma). 

2. Ectropion from relaxation of the lid-margin: (a) in paralysis of 
the orbicularis muscle (paralytic ectropion), and (b) in relaxation of the 
tissues and loss of the muscle-tone of the palpebral portion of the orbicularis 
(the ectropion of chronic conjunctivitis, chronic inflammation of the lid- 
margins, and of senility). 



Fig. 153.—Cicatricial ectropion. (Author.) 


3. Ectropion from malposition of the tissues in consequence of pressure 
on the lid-margin from behind, or from backward traction on the convex 
tarsal surface: (a) spastic ectropion, (b) in ectasias or tumors of the 
anterior part of the globe with exophthalmos, (c) from pressure on the 
lower lid hv conjunctival and tarsal tumors, (d) from traction of tumors 
on the peripheral part of the tarsus or on the conjunctiva. These are cases 
of mechanical ectropion. 

The symptoms of ectropion are the turning out of the lid, epiphora, 
and thickening of the conjunctiva. The skin of the cheek is eczematous. 
If the ectropion is slight, it causes so little discomfort that many persons 
do not seek relief. If the eversion is great, corneal complications are likely. 

Treatment. —The treatment of ectropion is operative, and will be 
considered in the latter part of this chapter. 





DISEASES OF THE EYELIDS. 


193 


Entropion, a turning in of the lid, is either muscular or organic. The 
former is seen as a result of bandaging in elderly persons whose eyes lie 
deeply in the orbits. It occurs also in infants at birth, from excessive 
development of the orbicularis muscle; and is found at different ages in 
spasmodic form from irritation accompanying conjunctivitis, keratitis, and 
the lodgment of foreign bodies. Organic entropion is commonly caused 
by trachoma. It also follows diphtheritic conjunctivitis and essential 
shrinking of the conjunctiva (Fig. 6, Plate VII). 

The effect of entropion is to place the skin of the lid in contact with 
the globe of the eye. The lashes constantly rub against the cornea and 
produce characteristic changes in that tissue. The epithelium becomes 
abraded and the deeper layers of the cornea become necrotic. Pannus 
develops and vision is much reduced. 

Treatment.— The muscular or spastic form of entropion generally 
improves with the removal of the cause. In infants the application of 
collodion to the outer surface of the lid will be beneficial, or the inversion 
may be overcome by adhesive plaster. Organic entropion, so often asso¬ 
ciated with trichiasis and blepharophimosis, requires operative treatment. 

INJURIES OF THE EYELIDS. 

Wounds of the Lids may be punctured, incised, lacerated, or contused. 
Punctured wounds are of little importance provided other ocular structures 
are not injured. They generally heal without scars. It must be remem¬ 
bered that numerous cases are recorded in which foreign bodies, after 
traversing the lids, have lodged and remained in the orbit without pro¬ 
ducing acute symptoms. Incised and lacerated wounds call for careful 
attention. They should be cleansed and accurately approximated with 
catgut sutures. It is especially important to note whether the canaliculus 
has been cut or the globe injured. Horizontal cuts do little harm except 
the suspensory ligament of the upper lid is severed. Vertical and oblique 
incised wounds, unless seen early and properly sutured, will lead to colo- 
boma, ectropion, entropion, or trichiasis. When the internal palpebral 
ligament and canaliculi are cut, the function of the lacrimal apparatus will 
be interfered with. Lacerated wounds, often produced by bursting bottles, 
meat-hooks, blows, or thrusts with pieces of wood or a cow’s horn, button¬ 
hooks, etc., if treated early will generally give good results. If the cana¬ 
liculus is torn, the remaining portion should be sought and opened into 
the sac. It may be possible to unite the two portions by passing a short 
probe, suturing the lid upon it, and leaving the instrument in place for 
a few days. Each case of laceration must be judged by itself, and often the 
ingenuity of the surgeon will be taxed. 

Contused wounds of the lids, frequent in persons pugilistically inclined, 
are followed almost immediately by extravasation of blood into the cellular 
tissue, producing a condition commonly called “black eye.” The blood may 
be in the form of a diffused ecchymosis or as a hematoma. For prognostic 


13 


194 


MODERN OPHTHALMOLOGY. 


reasons, it is important to distinguish between such an immediate ecchy- 
mosis and that which, occurring in fractures of the base of the skull or 
rupture of orbital vessels, appears later. In such serious injuries, the blood 
not infrequently is forced forward into the eyelids. The lower part of the 
ocular conjunctiva and the lower eyelid (rarely the upper lid also) show 
hemorrhages. The ordinary “black eye” disappears in two or three weeks. 
If a fracture has involved the frontal or ethmoidal sinus, emphysema, 
occurring early, may be associated with a tardy ecchymosis. Edema of the 
lids is a common result of a blow. 

Treatment. —A “black eye” should be bathed with cold water and 
treated with frequent applications of arnica, lead-water, laudanum, or 
hamamelis. If the blood is present as a hematoma, it will be best to incise 
the lid and evacuate the clots under aseptic precautions. Abscess of the 



Fig. 154.—Burn of face and eyelids. (Vail.) 

lid should be treated by incision and the frequent use of a bichlorid solu¬ 
tion. Leeches are of no particular value in the treatment of black eye. In 
sensitive persons the surgeon may conceal the injury by painting the eyelids. 

Burns and Scalds of the Eyelids, if of the first or second degrees, 
generally heal without deformity. Deeper lesions are frequently followed 
by cicatricial contraction, displacement of the lid-borders (ectropion), 
ankyloblepharon, or symblepharon. These conditions will require appro¬ 
priate surgical treatment. When called to a case of burn or scald, involving 
the lids, the surgeon should note carefully the condition of the conjunctiva 
and cornea. The injured area should be treated with gauze soaked in 
carron-oil, or with lint soaked in a solution of borax or sodium bicarbonate, 
or painted daily with white lead. Iodoform may be dusted on the surface 
daily. Large granulating surfaces should be covered with Thiersch’s skin- 
grafts. The principles which guide the surgeon in the treatment of burns 


DISEASES OF THE EYELIDS. 


195 


and scalds elsewhere in the body will apply to lid injuries. Pain may be 
so severe as to call for the use of morphin. 

Foreign Bodies in the Eyelids. — With the exception of grains of 
powder, the retention of foreign bodies within the eyelids is of comparatively 
rare occurrence. Pieces of iron, steel, gun-caps, coal, pencils, splinters of 
wood, birdshot, dirt, sand, and pebbles are among the substances occasionally 
found in the lids. Most foreign bodies carry infection with them and 
produce localized abscesses. In the course of the inflammation the foreign 
body often is extruded. Metallic bodies, which have been propelled by an 
explosion, are often sterile and remain imbedded in the lids without causing 
reaction. 'Large foreign bodies can be removed through suitable incisions. 
Small ones can be picked out with a cataract-needle. If the patient is seen 
shortly after the accident, grains of powder can be removed by scrubbing 
with a nail-brush. The continued use of gauze soaked in hydrogen peroxid, 
applied soon after the accident, is said to be of value. If these measures 
fail, the surgeon should wait until the acute stage has passed, when the 



Fi<j. 155. —Result of burn of face and eyelids. (Vail.) 


individual grains may be picked out through small incisions or destroyed 
with the fine point of an electric cautery (Jackson). 

OPERATIONS ON THE EYELIDS. 

The eyelid and conjunctiva and adjacent parts (skin of the cheek, 
forehead, etc.) should be made surgically clean, as is described in the 
chapter on preparation for ophthalmic operations. All instruments and 
dressings should be sterile. The surgeon and his assistants should thor¬ 
oughly clean their hands. Lid operations can be performed, as a rule, 
under local anesthesia. A solution of cocain (2- to 4-per-cent, strength) 
is to be dropped into the conjunctival sac as well as injected beneath the 
skin of the eyelid. General anesthesia will be required for children, and 
for some of the extensive plastic operations on adults. 

Chalazion Operations.—In operating on chalazion, a lid clamp should 
be used to control hemorrhage and give a solid substance on which to cut. 
The author has modified Snellen’s clamp (Fig. 156), and finds the new 
modification an admirable instrument. The incision can be made from the 
skin or conjunctival surface. If the surgeon is simply to incise and curette 




196 


MODERN OPHTHALMOLOGY. 


the cyst, the incision should be conjunctival; if he desires to excise the 
tumor, it will be best to make the cut in the skin parallel with the lid- 
margin. After excising the chalazion the wound is closed with two or 
three fine sutures. If the conjunctival incision is employed sutures are 
not necessary. Some surgeons incise chalazia and remove the contents by 
curettement. If the chalazion is situated near the lid-margin a neat 
operation is this: The surgeon grasps the lid with the thumb and index 
finger of the left hand, making traction in the direction of the lid-margin. 
Then the margin is incised with a von Graefe knife. Through this opening 
a curette is 'introduced and the tumor is removed by its use. 

Operations for Ptosis.—These are numerous, and many of them are 
inefficient. Cases of ptosis are divisible into: 1. Those in which the con¬ 
dition is congenital and the levator is absent or imperfectly developed. 2. 
Those due to defective development of the nerve-centre of the levator, to 

# 

which class belong those cases of congenital ptosis that can lift the upper 
lid only in association with certain movements of the jaw. 3. Those of 
acquired complete paralytic ptosis. 4. Those in which the upper lid droops 



after trachoma or the growth of tumors in the lid (hypertrophic ptosis or 
ptosis adiposa). 5. Those which are due to trauma. 

It might seem that shortening of the levator of the upper lid would 
suffice to correct ptosis, but such procedures have generally given poor 
results, and are of value only in cases of traumatic separation of the levator 
from the tarsus. It is only in the cases of slight ptosis that the ingenious 
procedure of Eversbusch (doubling of the levator muscle over the tarsus)’ 
is applicable. Von Gracfe’s operation of excising an elliptical portion of 
the skin and underlying tissues down to the tarsus is almost valueless, since 
in most cases either the deformity soon returns or the cornea is insuffi¬ 
ciently covered. Operations which aim to unite the occipito-frontalis muscle 
and the lid are ingenious, and some of them are of value. The procedure 
which the author believes to be the most efficient of all is Wilder’s operation, 
which aims to lift up the lid so that the eye can be used and at the same 
time permits the lids to close at will. It consists in folding the tarso-orbital 
fascia, as well as the aponeurosis of the levator muscle, upon itself. In 
performing this operation an incision two inches long is made in and 







DISEASES OF THE EYELIDS. 


197 


parallel with the eyebrow. “A retractor being used to draw down the lower 
lip of the wound, the skin and muscle are separated from the fascia by 
careful dissection until the tarsus is brought into view. This is more 
easily accomplished if an assistant puts the lid on the stretch. Sutures 
of fine sterilized catgut or silk, armed at each end with a curved needle, 
are passed into the tarsus to secure a firm hold at a point about at the 
junction of the outer and middle third and a little distance from its convex 
edge (o in Fig. 157). It is then drawn through and with it several gath¬ 
ering stitches (u) are taken in the tarso-orbital fascia, after which the 
needle is made to pass through the muscle and connective tissue of the 
upper lip of the wound. Another needle, on the same suture, follows a paral¬ 
lel course in the same manner, entering the tarsus about three millimetres 
from the point of entrance of the first, then gathering the fascia into small 
folds and emerging in the tissue above, thus making a loop by which the lid 
may be drawn up. A second suture is passed in the same way, making a 



Fig. 157.—Wilder’s operation for ptosis. 

T, Tarsus, t, t, Tarso-orbital fascia, sm, Supra-orbital margin, p, Lower lip of 
wound drawn down, u, u, Sutures. 


loop at the junction of the middle and inner third of the tarsus. The 
requisite elevation of the lid may now be secured by drawing on the loops 
and tying the sutures which are to be buried in the wound/’ The author 
can confirm Wilder’s statement that “complete ptosis may be relieved by 
shortening the suspensory ligament of the lid with buried sutures.” 

Panas’s Operation, which can be understood by examination of the 
accompanying illustrations, has been extensively practiced with fair results. 
The objections to it are that, in placing the rectangular flap under the 
bridge, a skin surface is opposed to raw tissue. In healing a pouch is left 
in which dirt accumulates, and in some cases the growth of hair from the 
buried flap causes annoyance. This operation raises the tarsus and permits 
the occipito-frontalis muscle to discharge in large part the functions of 
the absent or paralyzed levator. 

Van Fleet and Allport have modified Panas’s operation. 

The principles of the von Graefe and Panas operations have been 
combined in Tansley’s procedure, which is performed in this manner: The 








198 


MODERN OPHTHALMOLOGY. 


surgeon makes two perpendicular cuts (Fig. 160, A, B, G, D ) one-fourth 
of an inch apart, and extending from the upper orbital margin to within 
two lines of the edge of the upper lid. These are united at the upper 
extremity by a horizontal incision, A-G , and then the ribbon of tissue is 
dissected and permitted to drop down upon a wad of cotton lying upon 
the cheek, which is kej)t moistened with warm Panas’s solution. 

Then a curved cut is made from H to G and E to F , following the 
crease which shows the upper limit of the tarsal cartilage, and a straight 
cut is made from H to B and from D to F, parallel to and about four milli¬ 
metres distant from the lower border of the upper lid. The derma and the 
orbicularis muscle, which are embraced within these cuts, are then care¬ 
fully dissected off, leaving the whole tarsal plate denuded of tissue. This 
denuded surface is carried a trifle beyond both the internal and external 
canthi. The cut edges H-G and E-F are united to the cut edges H-B and 
D-F, respectively, by interrupted sutures. Then a von Graefe -knife is 



v a a 

Fig. 158.—Incisions and sutures in Panas’s operation 


entered at A-C and passed beneath and brought out upon the forehead 
just above the eyebrow, and slight lateral cuttings are made so as to give 
room for the passage of the ribbon of derma which has been dissected up 
at the first stage of the operation. Then passing a strong suture into the 
upper edge of this ribbon, it is drawn up into the cut made beneath the 
eyebrow, and is brought out upon the forehead. When drawn up suffi¬ 
ciently tight, so as to leave no folds of tissue or puckerings, it is cut off 
smooth with the forehead and fastened there by two small sutures. Then 
several sutures are placed from A to G and C to E, uniting the edges of 
the ribbon to the bordering derma. 

The relief of ptosis by a permanent wire suture is the feature of 
Mules’s operation. Its author described the procedure as follows: “Two 
needles with eyes near their points were passed deeply through the frontalis 
tendon over the eyebrow, and their points brought out at the margin of 
the lid behind the lashes, taking up a substantial part of the tarsal cartilage 





DISEASES OF THE EYELIDS. 


199 


on their way. A piece of silver wire was threaded through each needle, 
which was then withdrawn, leaving the loop of wire passing from the brow 
to the edge of the lid and back to the brow again. This was then tight¬ 
ened until the lid was sufficiently raised, the edge of the lid being grooved 
by an incision to allow the wdre to sink into the substance of the lid. One 
end of the wire was then passed under the skin and made to emerge by the 
side of the other end of the wire. The two ends of the wire were then 


Fig. 159.—Appearance of the eye after Panas’s operation. 

twisted on each other until the lid was raised permanently, the ends were 
cut off, and the wire allowed to sink below the level of the skin. The skin 
at this point and the lid-margin healed over the wire, which remained per¬ 
manently fixed in the substance of the lid. From further experience it was 
found that the wire remained in position without causing irritation; the 
lids could be closed, and remain closed during sleep. All kinds of wire had 
been tried, but it had been found that silver wire was the most satisfactory. 




Fig. 160.—Operation for ptosis. (Tansley.) 


It was necessary to note at the time of the operation the situation of the 
twisted end of the wire in case it became necessary to remove the suture 
afterward.” 

The ptosis remaining after trachoma can best be corrected by sutures 
introduced in the manner similar to Hotz’s operation for entropion. Other 
ptosis operations, which can be mentioned only by name, have been devised 
by Snellen, Eversbusch, Wolff, Hess, Pagenstecher, Birnbacher, Dransart, 
Kunn, Motais, Parinaud, and Gillet de Grandmont. 











200 


MODERN OPHTHALMOLOGY. 


Tarsorrhaphy.-—This operation is performed for the purpose of nar¬ 
rowing the palpebral fissure, and is done for the following conditions:— 

1. In lagophthalmos, when the cornea is partly uncovered during 
sleep and consequently is liable to necrosis. The condition may be due 
to congenital malformations of the lid (ablepbaria), paralysis of the 
orbicularis muscle, or to traumatic lesions of the lids. 

2. In exophthalmos, particularly that of exophthalmic goitre. 

3. In ectropion of an}^ form, and particularly in that of the paralytic 
variety. 



Fig. 101.—Tarsorrhaphy by von Graefe’s method. (Czermak.) 


4. In plastic operations. 

5. In excision of the Gasserian ganglion tarsorrhaphy is done before¬ 
hand to prevent corneal ulceration. 

Tarsorrhaphy may be external, internal, median, or total. External 
tarsorrhaphy can be done by either the method of von Graefe or that of 
Fuchs. In the former a sufficient amount of the outer end of each lid- 
margin is denuded and sutures are passed as shown in Fig. 161. In Fuchs’s 



Fig. 162.—Tarsorrhaphy by Fuchs’s method. (Czermak.) 


operation (Fig. 162) an incision, made in the intennarginal line, separates 
the cutaneous part of the lower lid from the tarsus. On the upper lid an 
area of corresponding extent is denuded; then by means of a single suture 
tiie parts are brought together. In median tarsorrhaphy the denuded sur¬ 
faces are situated on the central part of the lids. 

Canthoplasty (Blepharotomy).—The operation of canthoplasty, tar- 
sodialysis, or blepharotomy, is made for the purpose of enlarging a palpe¬ 
bral opening which is abnormally small. The most common cause of this 
condition is trachoma. Congenital smallness of the palpebral opening may 









DISEASES OF THE EYELIDS. 


201 


be an hereditary characteristic. In almost all operations for entropion a 
canthoplasty, or at least a canthotomy, must be made before the lid-clamp 
can be applied and the entropion properly treated. In this case the can¬ 
thotomy is simply a part of the operative procedure for entropion. In 
making a canthoplasty a local anesthetic should be dropped on to the 



Fig. 163.—Von Ammon’s canthoplasty. (After Czermak.) 

conjunctiva as well as injected beneath the skin at the outer canthus. The 
instruments needed are a pair of straight scissors, a needle, a needle- 
holder, and forceps. The surgeon introduces one blade of the scissors 
beneath the outer canthus, and cuts outward to the malar bone or to a 



Fig. 164.—The sutures in place in canthoplasty. 
(After Czermak.) 


less extent. The conjunctiva and skin are then to be united by sutures and 
an appropriate dressing is applied. 

Trichiasis Operations.—When only a few cilia are at fault, they may 
be removed from time to time with cilium forceps, or the follicles can be 
destroyed by electrolysis according to the method of Michel, of St. Louis. 
The latter is a slow and painful procedure. In these cases the affected part 
of the lid should be transplanted. A straight keratome is introduced at 





202 


MODERN OPHTHALMOLOGY. 


the intermarginal line, and is made to split the lid into two parts, the 
hair-follicles being in the flap in front of the tarsus. The operation can then 
be finished in one of two ways: either the part bearing the faulty cilia can 
be excised by removing a triangular segment of skin, as is done by Stephen¬ 
son, or, as the author prefers, a button of skin can be removed, the lid- 
border and cilia being transplanted. The latter procedure is to be pre¬ 
ferred. The wound is to be closed with catgut sutures. Desmarres, Sr., 
treated these cases by the excision of a small oval piece of skin and trusted 
to cicatrization to draw the cilia away from the globe. 

In case the greater part of the eyelid is involved in trichiasis, a gen¬ 
eral transplantation of cilia must be done. For the relief of this condition 
no procedure is so valuable as a properly-made Jaesche-Arlt operation. 
In patients with trichiasis it is always wise to permit the cilia to be undis¬ 
turbed for at least a week before operation, in order that the surgeon shall 
locate them without difficulty. The instruments needed are a lid-clamp, a 



Pig. 165.—Excision operation for trichiasis. (After Stephenson.) 

The dotted lines show the parts removed in the excision operation ; the oval marks the 
tissues removed in the author’s method. 


scalpel, fixation-forceps, needles, needle-holder, scissors, and a sharp and 
strong von Graefe or Beer knife for splitting the lid. The first step is the 
separation of the lid into two parts: an anterior, containing the skin, 
muscular fibres, and cilia; and a posterior, composed of tarsus and con¬ 
junctiva. To do this the surgeon grasps the everted lid between the left 
thumb and index finger, and passes the knife to the depth of 3 or 4 milli¬ 
metres along the intermarginal line from near the punctum to the outer 
canthus. To make this incision properly is sometimes difficult, yet its 
correct performance has much to do with the success of the operation. The 
lid-clamp then being applied, an elliptical piece of skin and other tissues 
is removed down to the tarsus. The next step is to connect the inter¬ 
marginal incision with the wound on the outer surface of the lid, thus 
making a bridge which consists of skin and orbicularis muscle, free above 
and below, but attached at either end. This bridge is then to be sutured 
to the upper edge of the lid-wound. The result is that the bridge bearing 
the cilia is moved away from the lid-margin and the hairs are given a 
normal direction. To prevent cicatricial contraction some surgeons use 




DISEASES OF THE EYELIDS. 


203 


the excised piece of skin to cover the raw surface of the tarsus. Others 
transplant a piece of the mucous membrane of the mouth into the wound. 
These devices are not necessary. The sutures are to be removed in four 
or five days. The lid will remain thickened for several weeks. Sloughing 
of the bridge has never occurred in the author’s practice. 

Some surgeons make the intermarginal incision in this way: Jaeger’s 
lid-plate is placed under the lid and a keratome is used to make the in¬ 
cision, the lid being supported by an assistant. 

Entropion Operations.—Of the many procedures for the relief of 
entropion, Snellens operation lias probably given the most satisfactory 
results. It is applicable to cases of organic entropion: i.e ., to those in 
which the tarsus is incurved. The instruments needed are the licl-clamp, 
scalpel, tissue-forceps, needles, needle-holder, suture material, and a half- 
dozen beads. The clamp having been applied, an incision 4 millimetres 
from the lid-margin is to be made along the length of the upper lid. A 



Fig. 166.—Jaesche-Arlt operation for trichiasis. 

The figure at the left shows the incisions, A being the cut in the intermarginal line, and 

B, C, the skin removed. 


second incision, 2 or 3 millimetres higher, connects with the first cut. The 
skin and orbicularis muscle included between these incisions are to be re¬ 
moved, thus exposing the tarsus. The surgeon should pass his finger along 
the tarsal plate and notice the place of greatest convexity, from which a 
wedge-shaped segment is to be excised. To do this properly requires a 
very sharp scalpel or a Beer cataract-knife. The long diameter of the 
excised wedge is to be parallel with the lid-margin. The next step, the 
insertion of the sutures, is of importance, and is often improperly described. 
The sutures are usually three in number, each one being armed with a needle 
at each end. One needle is to be passed into the upper segment of the tarsal 
tissue parallel with the wound, so as to include about 2 or 3 millimetres 
of tissue. The two needles of this suture are now to be passed through 
the lower segment of the lid, 5 millimetres apart, in this manner: Grasping 
the lid-margin with tissue-forceps, the surgeon passes each needle from 
the point G (Fig. 167) to G. This procedure is to be repeated with the 
two other sutures. Then the lid-clamp is to be removed and a bead is to 
be strung on each end of each suture, the sutures being tied and the ends 







204 


MODERN OPHTHALMOLOGY. 


left long. The ends are then drawn taut against the forehead, thus everting 
the lid. They are to be fastened in this position by strong adhesive plaster 
strips. There will be no need for suturing the skin in this operation, since 
the eversion which follows the fastening of the sutures to the forehead causes 
the lips of the skin-wound to approximate. A dry gauze dressing is to be 
applied. The sutures are to be left attached to the forehead for two days, 



Fig. 1G7.-—Section of the upper eyelid in Snellen’s operation for entropion. 

S, S, Skin. T, T, Tarsus from which a wedge has been cut. 6, G, Suture. 

after which the ends are to be cut off and the lid is permitted to assume 
its proper position. On the fourth day the beads and deeper part of the 
sutures are to be removed. 

For obvious reasons Snellen’s operation is applicable only to the upper 
lid. In case the lower lid is incurved, Hotz’s operation should be per¬ 
formed. A spatula having been placed under the lid, an incision 4 milli¬ 



ng. 168.—The method of placing the sutures in Snellen’s operation for entropion. 

T, Tarsus. S, Skin. 

metres removed from, and parallel with the lid-margin is to be made, and 
narrow pieces of skin and orbicularis muscle are to be removed. This 
exposes the lower margin of the tarsus. If it does not come promptly into 
view, the edges of the wound are to be held apart and the soft tissues are 
to be dissected down to the tarsus. All muscular fibres adhering to the 
lower third of the tarsus must be removed. A needle is to be passed through 
the palpebral skin; then it is carried through the bared edge of the tarsus 



















DISEASES OF THE EYELIDS. 


205 


into the tarso-orbital fascia for a short distance, and is then passed through 
the lower edge of the incision without including any muscular fibres. Two 
other sutures are to be used in a similar manner. When tied, the sutures 
bring the skin into contact with the tarsus, to which it adheres. Thus 



Fig. 169.—Hotz’s operation for entropion. 

C, Cornea. T, Tarsus, co, Conjunctiva, sc, Sclera, tt, Tarso-orbital fascia, x, Orbital fat. 

■mb, Malar bone, ob, Orbicularis muscle, ss, Suture, c, Cilium. 

I, i, Lips of wound. 

the tarsus is made the fulcrum: a point which Hotz emphasizes. This 
operation is applicable to either lid. It is proper to state that an operation 
founded on the same principle as that of the Hotz procedure was described 
by Anagnostakis in 1357. 



Fig. 170.—Harlan’s operation for entropion. 

Harlan's Operation. —The lid is to be split in the ordinary manner 
and a horizontal strip of skin and muscle is removed. The anterior seg¬ 
ment of the lower half of the lid is not converted into a bridge. The sutures 
are passed through the posterior segment of the lid, then looped over the 




















206 


MODERN OPHTHALMOLOGY. 


anterior segment, and the needle is passed deep into the orbicularis muscle, 
emerging 5 millimetres above the wound. When tied, the sutures draw the 
tarsus and conjunctiva downward and the cilia-bearing segment forward. 

In cases of spastic entropion the thread operation of Snellen is useful. 
The object is to draw the margin of the lid away from the globe and to 
form in the lid cicatricial bands which shall continue to maintain it in 
proper position after the sutures have been withdrawn. A thread, armed 
with two needles, is to be passed through the deepest part of the lower fornix 
and is brought out through the skin; then each needle is reintroduced and is 
made to pierce the full extent of the lid, being brought out at the outer lip of 
the lid-margin. The threads are then tied tightly over a small roll of 
gauze. Two or three such threads are used. The points of exit on the 
lid-margin are to be the same distance apart as the space separating the 
threads in the fornix. This operation is chiefly of use in entropion of the 



Fig. 171.—Von Ammon’s operation for epieanthus. 


lower lid. Other suture operations for spastic entropion have been devised 
by Gaillard and Arlt. 

Ewing's Opebation is applicable to atrophic entropion of the lower 
eyelid. A longitudinal incision is made “through the tarsal conjunctiva 
and the tarsus, parallel to and from two to three millimetres distant from 
the line of the opening of the Meibomian glands. This incision, extending 
through the entire thickness of the tarsal tissue from its nasal to its tem¬ 
poral end, permits the whole marginal strip to be turned’ forward, to form 
a new lid-margin of normal width and appearance.” The strip is held in 
place by sutures. The cut on the conjunctival side fills with new tissue, 
which increases the height of the tarsus two or three millimetres. 

Epieanthus Operations.—Eor the relief of epieanthus the excision of 
a vertical fold of the redundant tissue from the root of the nose, as 
practiced by von Ammon early in the last century, has stood the test of 
time. The tissues are to be lifted up to an extent sufficient to remove the 
deformity, and on each side a mark is to be made to indicate the location 
of the incisions. The elliptical area thus outlined is to be excised. The 








DISEASES OF THE EYELIDS. 


207 


lips of the wound are to be united with line sutures (Fig. 171). Every 
precaution should be taken to secure primary union and avoid an unsightly 
scar. Wicherkiewicz has recently described an operation which can be 
readilv understood by an examination of Fig. 172. 

Recently Broekaert has successfully used paraffin injections beneath the 
skin over the root of the nose in cases of epicanthus. This treatment is 
not without danger. Leiser has reported a case in which it caused vomiting, 
total blindness of the left eye, edema of the lids, hemorrhagic infiltration 



Fig. 1 72.—Wicherkiewicz’s operation for epicanthus. 
A, After excision. B, After the sutures have been tied. 


of the iris, and hypotony. These symptoms were attributed to thrombosis 
of the ophthalmic vein. Hurd and Holden observed embolism of the cen¬ 
tral retinal artery immediately after a paraffin injection into the nose. 

Ectropion Operations. — Acute ectropion results from inflammatory 
swelling and requires treatment of the accompanying conjunctivitis. In 
severe cases it may be necessary to scarify the chemotic membrane. In ec¬ 
tropion due to spasm of the orbicularis muscle a canthotomy can be done 
with benefit. In senile ectropion with simply a falling away from the globe 



Fig. 173.—Snellen’s thread operation for ectropion. 

The figure at the left shows the thread in position to be tied ; the figure at the right 

shows the lid after tying. 


of the inner part of the lower lid, slitting of the canaliculus without other 
treatment will be in order. In cases of senile ectropion of the lower lid, 
and in the ectropion of children from swelling of the conjunctiva, and with 
only slight elongation, Snellens thread operation (Fig. 173) is valuable. 
A stout silk thread, armed with a curved needle at each end, is to be passed 
into the tissues at the highest point of the everted conjunctiva and brought 
out upon the cheek. The ends are tied over a roll of gauze and the lid is 
thus held against the globe. The cicatricial bands which form in the track 











208 


MODERN OPHTHALMOLOGY. 


of the suture are expected to maintain the lid in position. The suture is 
to be removed at the end of four or five days. 

Where the lid is much elongated and sags to a considerable degree, 
particularly in cicatricial ectropion, the surgeon has the choice of three 
procedures: (1) the lid can be supported by the transference of a skin- 
flap from the malar region, as in von Langenbeck’s operation, (2) one of the 
numerous excision operations can be done, or (3) the Hotz operation can 
be performed. 

Yon Langenbeck's Operation, which is highly commended by Ber- 
nays, is to be done by making an incision in the skin from one canthus 
to the other, 2 or 3 millimetres from the lid-margin. The deeper tissues 
are then to be divided and an assistant pulls the lid into place. The sur¬ 
geon then makes a skin-flap, of the shape shown in Fig. 174, and sews 
it into the wound. The skin-flap must be much larger than the space 



Fig. 174.—Von Langenbeck’s operation for ectropion. 
A, Incision. B, After suturing. 


to be covered, to allow for shrinkage. The redundancy of tissue in the 
lower lid will disappear. 

The excision operations for ectropion are numerous. Von Ammon s 
operation consists in the removal of a triangular segment from the outer 
canthus, the base of the triangle being toward the eyeball (Fig. 175). 
Dieffenbach’s operation combines a tarsorrhaphy with the excision of a 
triangle, with the base up (Fig. 176), from the outer canthus. Sanson’s , 
often misnamed Adams’s, operation consists in the excision of a wedge- 
shaped piece of the whole thickness of the lid (Fig. 177). 

Robertson's First Operation (Fig. 178) was a modification of 
Snellen's procedure. A strong silk suture, armed with two needles, is to 
be passed through the anterior part of the lower lid (b , b) and is to be 
brought out on the conjunctival surface (a, a). Then it is to be passed 
from the highest point of the eversion downward to emerge on the 
cheek (d, d). Before tying the suture a piece of lead (c) covered with 







DISEASES OF THE EYELIDS. 


209 


India-rubber tubing is placed beneath the loops of the suture. The upper 
end of the rubber-covered piece is to be curved to suit the curve of the eye¬ 
ball. The lids are then to be closed and the suture tightened. The result 



Fig. 175.—Von Ammon’s operation for ectropion. 


is that the edge of the lid assumes the normal position. The tubing and 
suture are to be removed at the end of a week. This operation is applicable 
to senile ectropion of the lower eyelid. 



Fig. 176.—Dieffenbach’s operation for ectropion. 

Robertson's Latest Operation seems to be applicable to several 
forms of ectropion of the lower lid. An incision is made through the 
skin of the outer third of the lower lid and is continued upward 12 or 


Fig. 177.—Sanson’s operation for ectropion. 

15 millimetres. It is then to be carried outward 6 millimetres and then 
downward about 25 or 30 millimetres. The flap of skin thus outlined is 
to be dissected. A Y-shaped piece is next removed from the entire thick¬ 
ness of the lid near the outer canthus. Traction upward is now to be made 





14 















210 


MODERN OPHTHALMOLOGY. 


on the skin-flap until the lid is placed in normal position. The excess of 
the skin-flap is cut off and the parts are united with sutures (Fig. 179). 

Ivuhnt's Operation consists in the excision of a triangular piece of 
the tarsus and conjunctiva, the base of the triangle being at the lid-margin 
and the apex at the fornix. The wound is closed by means of sutures 
placed horizontally on the inner surface of the lid, and one external suture. 
The steps in the operation are shown in Figs. 180 and 181. This procedure 



is applicable to those cases of ectropion of the lower lid in which the lid 
is elongated chiefly at the margin. After the sutures are tied, the conjunc¬ 
tiva around the wound is dusted with iodoform, the skin of the lids is 
anointed with sterile vaselin, and a dressing of sterile gauze is applied. 
The sutures are removed on the fourth day. Kulmt’s operation is of value 
in cicatricial ectropion in addition to the required plastic procedure, but, 
as a rule, it is of greatest value in senile ectropion and in eversion of the 
lower lid from trachoma. 





Fig. 179.—Robertson’s latest operation for ectropion. 


L. Muller’s Operation is a modification of that of Kuhnt. The 
accompanying illustrations (Fig. 182) make a detailed account of this 
procedure unnecessary. 

Hotz's Operation for Cicatricial Ectropion is to be recom¬ 
mended. 

In operating upon the lower eyelid (Fig. 183) the incision, g-m-b, is 
begun 1 centimetre below the inner canthus and is carried obliquely into 











DISEASES OF THE EYELIDS. 


211 


the cheek to a point 3 centimetres below the centre of the everted lid-margin. 
It is then extended upward and outward to the point b (Fig. 183), even 
with and 1 centimetre from the outer canthus. This large flap, g-m-b , is 
dissected from the underlying scar-tissue and all cicatricial bands are 
cut. The overstretched lid-margin is then reduced to its proper size by 



Fig. ISO.—Kuhnt’s operation for ectropion. 


removing a suitable piece (except the conjunctiva) near the outer canthus, 
cutting from a to c along the lid-margin and from c to d through the 
flap. The. edges c-d and a-b are then united by two silk sutures. The 
lid is now drawn up as far as possible and is held by two silk sutures, 
which are passed through the free margin and fastened to the forehead 



Fig. 181.—Supporting stitch in Kuhnt’s operation. 


by adhesive plaster. The edge of the detached lid-flap is then anchored 
to the tarso-orbital fascia by silk sutures. The open surface is covered 
with a Thiersch graft whose edges are to lap over the surrounding skin. 

In operating on the upper eyelid (Fig. 184) Hotz begins his incision 
about 5 millimetres above the inner canthus, and continues it obliquely 
upward into the cicatricial skin and then downward to a point about 5 
















212 


MODERN OPHTHALMOLOGY. 


millimetres above the outer canthus. This incision outlines a large flap, 
a-b-c , which is dissected from the underl)dng scar-tissue as far as the lid- 
borders. The lid is then released by dissection from all cicatricial con¬ 
nections until it can be replaced in its normal position. The edge of the 
lid-flap is then fastened by silk sutures to the upper border of the tarsus. 
If, on account of the presence of the eyebrows, the lid-flap cannot be taken 



Fig. 182.—Muller’s ectropion operation. 


from the cicatricial skin, an incision is made along the lid-border. The 
lid is replaced and a large Thiersch graft is sutured to the upper tarsal 
border as well as to the wound edge of the free border. In placing the 
sutures care must be taken that the edges of the flap do not roll in. Strips 
of gutta-percha are laid over the flap; a gauze compress wet with warm 



m m 

Fig. 183.—Hotz’s operation for cicatricial ectropion of the lower eyelid. 

A, Lines of incision. B, The sutures in place. 

boric-acid solution is applied; and a protection layer of cotton and a 
bandage complete the dressing. The dressing is not disturbed before the 
third day. 

Subcutaneous Incision. —In rare instances cicatricial ectropion can 
be relieved by the subcutaneous cutting of contracted bands. The operation 
is done by means of a tenotome. 
























DISEASES OF THE EYELIDS. 


213 


Excision of the Cicatrix, without a plastic procedure, is applicable 
in a few cases where the scar-tissue is of limited extent. In general terms, 
however, it may be said that cicatricial ectropion demands a blepliaroplastic 
operation. 

Blepliaroplastic Operations.—These procedures are required in cica¬ 
tricial ectropion and in cases where destruction of a part or all of the lid 
occurs. The restoration may be made by grafting or by transplantation 



Fig. 1S4.—Hotz’s operation for cicatricial ectropion of the upper eyelid. 


of a piece of skin. Such operations are divisible into the following 
groups:— 

1. Operations in which a piece of skin bearing a pedicle is turned 
into a lid. This may be obtained (a) from neighboring tissue or (b) from 
a remote part. 

2. Operations in which the transplanted piece of skin is without a 
pedicle (method of le Fort). 



3. Operations in which small pieces of skin are grafted into a wound 
as a mosaic (Keverdin’s method). 

4. Operations in which the grafts of Ollier or of Thiersch are used. 
In all blepliaroplastic operations the strictest attention to asepsis is 

necessary. Often repeated operations will be required in order to secure 
the best result. Tension on the transplanted flap should be avoided, and 
in cutting the flaps fully 50 per cent, should be allowed for shrinkage. 
Wherever possible the pedicle should include a good-sized blood-vessel. 




214 


MODERN OPHTHALMOLOGY. 


Twisting of the pedicle should be avoided. Sutures are used only in lim¬ 
ited number; numerous sutures add to the danger of infection. Artificial 
warmth applied to the flap is unnecessary. A dry dressing should be applied 
to the parts and the wound should not be touched for two or three days. 
Syphilitics are not good subjects for plastic operations. 



Fig. 186.—Blasius’s blepharoplasty. 


Blepharoplasty with a Pedicle Derived from Adjacent Tissue. 
—The methods of blepharoplasty with a pedicle are numerous, and only a 
few can be mentioned. Fricke’s operation (1829) consists in filling an 
oval defect in the lid with a tongue-shaped flap taken from the forehead 
or cheek (Fig. 185). It is applicable to either lid. Fricke applied this 
operation to cases of extreme ectropion in which only the skin was de¬ 
stroyed, the conjunctiva and lid-margin being normal. 


A 

* 

/ • 



Fig. 187.—Blasius’s blepharoplasty. 


Blasius’s operation (1842) aims to restore the lower lid by a flap 
taken from the side of the nose (Fig. 186), not from the glabella and 
forehead, as has been stated by Meyer and de Wecker. The upper lid, how¬ 
ever, can be restored by taking the flap from the root of the nose and the 
forehead. The same surgeon devised several other ingenious operations, one 
of which is shown in Fig. 187. 

Hasner d’Artha’s Operation— This surgeon devised an ingenious opera- 








DISEASES OF THE EYELIDS. 


215 




tion (Fig. 188), by means of sliding flaps with curved margins, for cases 
in which removal of a large part of both lids becomes necessary. 

Dieffenbach’s Operation .—In this a triangular defect in the lower lid 
is covered with a quadrangular flap (Fig. 189). A modification of this 
operation was made by Szymanowski (Fig. 190). 


Fig. 1SS.—D’Artha’s blepharoplasty for both lids. 

Knapp’s Operation (Fig. 191) is valuable where the greater part of the 
lower lid must be excised for malignant disease. In cases of ulceration 
where there is involvement of both eyelids, an extensive plastic operation 
will be required, as in a case reported by Posey and Shumway (Figs. 192 
and 193). • 


Fig. 189—Dieffenbach’s blepharoplasty. Fig. 190.—The Dieffenbaeh-Szymanowski 

operation. 

BLEPH AttO PLASTY WITH A PEDICLE FROM A DISTANT PART. —An 
ancient operation, which is known as the Italian method, is the application 
to the eyelids of a procedure which the Branca family and Tagliacozzi 
applied in the fifteenth and sixteenth centuries to the restoration of the 
nose. The flap is obtained from the inner aspect of the arm. Because of 
the necessity of prolonged immobilization of the parts the method has never 
become popular. 












216 


MODERN OPHTHALMOLOGY. 


Blepharoplasty Without a Pedicle (Skin-grafting).—If the skin is 
obtained from the patient it is known as an autograft; if from another 
person, it is a heterograft; if from one of the lower animals, it is a 



Fig. 191.—Knapp’s blepharoplasty. 


zoograft. A heterograft or autograft generally grows better than a zoo¬ 
graft, although the heterograft may be the means of transmitting syphilis. 

Le Fort’s Method (the transplantation of flaps comprising the whole 
thickness of the skin without the subcutaneous fat) has been practiced sue- 



/ 

i 

/ 

/ /' 


Fig. 192.—Outlines of incision in blepharoplasty. (Posey and Shumway.) 

cessfully by le Fort, Sichel, Stellwag, and others. The procedure was 
popularized by the writings of Wolfe. In the operation from 30 to 50 per 
cent, should be allowed for shrinkage. Sutures may or may not be used. 
A dry dressing is applied. 







DISEASES OF THE EYELIDS. 


217 


Keverdin's Method.— In this procedure pieces of clean skin, one or 
two millimetres in diameter, are cut from the thigh or arm. The epi¬ 
thelium and a part of the corium are removed. Numerous such grafts are 
implanted upon the denuded surface at intervals of five to ten millimetres, 
and a gauze dressing is applied. This should not be disturbed for several 
days. If there is much suppuration the superficial layers of gauze can be 
changed daily and the parts can be washed with a solution of boric acid. 
Strong antiseptics should not be applied. 

Thiersch’s Method is generally believed to he the best means of 
closing skin-defects. Both the area to be filled and the surface from which 



Fig. 193.—Result of blepharoplasty. (Posey and Shumway.) 

grafts are to be cut must be clean (washed with soap and hot water and then 
with a solution of bichlorid of mercury) and should be kept moist with a 
physiologic salt solution (bicarbonate and chlorid of sodium, of each 0.3 
per cent.). With a sterile razor strips are cut which are to include only 
the epidermal and Malpighian layers. In this procedure the skin is held 
tense and the strips are cut with a gentle to-and-fro movement. They are 
then floated in the normal salt solution on to the area which is to be cov¬ 
ered. In this manner strip after strip is to be applied until the denuded 
area is covered. The strips should overlap one another and also should 



218 


MODERN OPHTHALMOLOGY. 


cover the skin. All bleeding should be checked before the grafts are placed. 
During the operation there may be doubt as to which is the raw surface 
of a particular graft. This can be determined by remembering that the 
graft rolls up toward the raw surface. A layer of gauze or of rubber tissue 
is to be applied and held in place by a bandage. The dressing should be 
smeared with sterile vaselin, so that the grafts will not become detached 
when the dressing is changed. Thiersch grafts are not only of value in 
closing defects of the eyelids and face, but are also applied to the bones 
of the orbit in cases requiring total removal (exenteration) of the orbital 
contents. They are also of value in symblepharon operations. The grafts 
will grow upon periosteum, bone, tendons, fascia, and muscle. 


CHAPTER VI. 

DISEASES OF THE LACRIMAL APPARATUS. 

Since the lacrimal apparatus naturally admits of division into a 
secretory and an excretory part, it will be proper to consider, first, the 
diseases of the gland, and, second, the diseases of the drainage system. 
Lacrimal diseases form about 2 per cent, of the practice of ophthalmolo¬ 
gists. 


DISEASES OF THE LACRIMAL GLAND. 

The lacrimal gland of the orbit is subject to inflammation, injury, and 
new growths. The accessory glands also take on certain morbid actions. 

Inflammation of the Lacrimal Gland (Dacryoadenitis) is a very rare 
disease, which may end in resolution, in suppuration, or in chronic 
adenitis. The inflammation may be acute or chronic. 

Acute Dacryoadenitis begins with pain, redness, and swelling of the 
upper lid and conjunctiva, particularly of the outer extremity of the lid. 
In the beginning of the attack an enlargement of the gland can be 
readily felt. On elevating the lid, the lower part of the swollen gland 
becomes visible. The skin is movable over the mass, and, in pronounced 
cases, the eye is protruded and depressed. The upper lid droops. In 
the acute stage the gland is very sensitive, and eversion of the lid cannot 
be performed. Under these circumstances the eye may present a picture 
resembling that of purulent conjunctivitis or orbital cellulitis. When 
suppuration occurs, the pus may escape through the skin of the lid or 
through the conjunctiva. Probably the lower anterior part of the gland, 
the so-called palpebral part, is more often inflamed than the main portion. 

Etiology .—Dacryoadenitis is more common in women and children 
than in men and adults. It sometimes occurs in epidemics in connec¬ 
tion with mumps. Injuries, exposure to cold, and certain blood diseases 
•—such as syphilis, gout, rheumatism, scrofula, and sepsis—and direct 
infection from the conjunctival cul-de-sac are causes. Metastatic dacryo¬ 
adenitis occurring in patients with gonorrhea has been described by Ter- 
son, Panas, and Ferry. 

Diagnosis .—Acute dacryoadenitis must be distinguished from orbital 
cellulitis. The differentation can be made by the location of the point 
of greatest intensity of the inflammation. In some cases diagnosis may 
be impossible until after exploratory incision. 

Treatment .—If a case of dacryoadenitis is seen in the earliest stage, 
the patient should be given a mild cathartic and any special medication 
which may be needed to combat any constitutional disease from which 

(219) 


220 


MODERN OPHTHALMOLOGY. 


he may suffer. The application of iced compresses is valuable. If the 
case is seen later, hot packs are to be applied to the region over the 
inflamed gland. Pus may form in a few days, in which case an incision 
must he made. The inflammatory symptoms may subside, and the case 
then becomes chronic. 

Chronic Dacryoadenitis is recognized by the history and by the 
presence of a swollen, lobulated, tender mass, situated at the outer and 
upper angle of the orbit. In a case of this character, seen by Snell, 
there was almost a complete absence of tears. Chronic inflammation 
of the gland may appear at any age. It is found in non-syphilitics as 
well as in syphilitics. Often its cause cannot be determined. 

The treatment comprises the local use of iodin and mercurial oint¬ 
ments, and the internal administration of iodid of potassium and bichlorid 
of mercury. There is abundant evidence of the efficiency of these reme¬ 
dies in those who do not give a specific history, as well as in syphilitics. 
Where there is a history of rheumatism, the iodid or salicylate of sodium 
is of value. The use of a compress bandage is recommended by Gale- 
zowski. 

Dacryoadenalgia is the name applied by A. Schmidt to neuralgia 
of the lacrimal gland. The condition is an extremely rare one, and it 
is a question whether the term should be retained in ophthalmic literature. 
Possibly cases of supposed neuralgia of the gland were examples of lesions 
or functional disturbances located elsewhere. 

Simple Hypertrophy, or Adenoma, of the Lacrimal Gland is rarely 
seen. It may be congenital or acquired. The enlargement may be so 
great as to cause optic-nerve atrophy by pressure and extrusion of the 
globe from the orbit. An interesting example of adenoma occurred in 
the practice of the late Dr. C. Johnston, of Baltimore. The eye, forced 
from its normal position, still retained its movements, and vision equal 
to the counting of fingers was preserved. On removal the gland was 
found to be the size of a hen’s egg and contained numerous dacryoliths. 
The diagnosis of simple hypertrophy may be difficult at an early stage. 
A rapidly increasing growth may be a simple adenoma, a malignant 
neoplasm, or a tubercular tumor. 

The treatment of hypertrophy should begin with the local use of 
iodin and the internal use of potassium iodid and bichlorid of mercury. 
Should this fail to check the process, recourse should be had to excision 
of the gland. 

Atrophy of the Gland occurs rarely and is generally associated with 
xerosis of the conjunctiva. It may be caused by the pressure of an 
orbital tumor. Destruction of the lacrimal sac is sometimes followed by 
absence of lacrimation of the same side, presumably due to atrophy. 
There is no treatment for this condition. 

Dacryoliths.—Concretions in the lacrimal gland are of rare occur¬ 
rence. If recognized, they should be removed by incision. 


DISEASES OF THE LACRIMAL APPARATUS. 


221 


Dacryops.—Cyst of the gland, or of an efferent duct, is a rare con¬ 
dition which may he present at birth, but is usually acquired. It forms 
a tumor varying in size from a pea to a pigeon’s egg, situated at the 
upper and outer part of the upper lid, and extending backward to the orbit. 
On everting the lid, a translucent, elastic swelling, of a bluish-pink color, 
presents itself. If the patient weeps, it may increase rapidly in size. 
Pressure may cause it to collapse. 

Treatment.— Dacryops is best treated by excision. Some authors 
have thought that, on account of the thinness of the wall of the cyst, 
excision is not possible. Mr. Arnold Lawson has reported a case in which 
this operation was successfully performed. 

Hydatid Cyst of the lacrimal gland has been reported by Fromaget. 

Fistula of the Lacrimal Gland may occur from trauma, dacryops, or 
abscess, or may be present as a congenital condition. The fistula opens 
on to the upper lid, and presents a minute orifice through which tears 
ooze forth. Under excitement or irritation the flow becomes profuse. 
The closure of such an opening is sometimes difficult, and, if the effort 
succeeds, it may cause dacryoadenitis. The older ophthalmologists re¬ 
sorted to heroic measures. Beer closed a fistula by passing a red-hot 
knitting-needle into the opening, and Mackenzie used a probe coated with 
lunar caustic. The simplest and most satisfactory way to deal with such 
cases is to excise the lacrimal gland, and at the same time cut out the 
tissue around the fistulous tract. Fistulse due to caries or necrosis of 
the orbital wall will heal only after the removal of the diseased bone. 

Dislocation of the Gland may be present at birth, follow trauma, 
or occur spontaneously. When it results from trauma, the parts should 
be cleansed, the gland replaced, the skin sutured, and a bandage applied. 
Bistis has recorded a case in which this treatment was successful. In 
traumatic luxation, where the gland is badly lacerated and the ducts are 
torn, it will be best to excise the mass. Its removal will not materially 
affect the moistening of the conjunctiva. 

Spontaneous luxation rarely occurs, the gland commonly presenting 
above the outer part of the upper lid. Noyes found it beneath the ocular 
conjunctiva, over the insertion of the external rectus muscle. Robertson 
removed a lacrimal gland dislocated into the upper lid, where it occupied 
the whole length and part of the breadth of the eyelid. If luxated chiefly 
into the lid, the gland should be anchored to the periosteum of the orbit. 
If this fails, excision will be in order. 

Syphilis of the Lacrimal Gland, although a rare condition, undoubtedly 
occurs. Such a case was recorded by Streatfeild. In any case of enlarge¬ 
ment of the gland in which the cause is not known, antisyphilitic treatment 
should be instituted before surgical intervention is practiced. 

Tumors of the Lacrimal Gland are not often seen. Aside from the 
cysts already mentioned, the new formations in this part are sarcomas 
of various kinds, carcinomas, myxomas, lymphaclenomas, chloromas, 


222 


MODERN OPHTHALMOLOGY. 


hydatids, dermoids, chondromas, angiomas, and concretions (dacryoliths). 
Buller and Byers have reported a case of primary carcinoma of the gland. 

The malignant tumors here grow rapidly. In many cases it will be 
manifestly impossible to make a diagnosis of the nature of a tumor of 
the lacrimal gland until after removal. If the growth does not subside 
under antisyphilitic treatment, it should be excised. 

Tuberculosis of the Gland has been described recently by de 
Lapersonne, L. Muller, Baas, Salzer, and Siisskind. The clinical features 
are the presence of a hard tumor, about the size of an almond, situated 
at the upper and outer part of the orbit. The tumor is movable and 
is not adherent to the skin. In one-half the cases the growth was rapid 
(two or three months) and suggested sarcoma. In the other half the 
disease progressed slowly (three or four years). In only one case was 
pain present at the beginning. In three cases the skin over the tumor 
was red and swollen. Nearly all the patients showed tuberculosis else¬ 
where. The movement of the eye was not limited. It is evident that 
the nature of the tumor in these cases can be determined only after re¬ 
moval. Microscopic examination shows typical miliary and submiliary 
tubercles, with more or less round-cell infiltration. The tubercle bacillus 
was found in less than half of the reported cases. Thus far caseation has 
not been reported. Surgical intervention will be in order only after 
medical and hygienic measures have failed. 

Chloroma. —A rapidly growing and very malignant and rare tumor 
of the gland is chloroma, which Dock states “is a lympliomatous process 
similar in its clinical features to leukemia.” The tumor is hard and 
becomes so large that the lids do not cover the eyeball. The lymphatic 
glands of the neck become enlarged, the blood shows an excess of leu¬ 
cocytes, and hemorrhages occur from the mucous membranes. In Ayres’s 
case the immediate cause of death was hemorrhage from the conjunctiva. 
On removal the tumor presents a light-greenish color; hence the name. 
It is a disease of early life, the average age of the reported cases having 
been fifteen years. 

Affections of the Accessory Glands are probably much more common 
than would be thought from the small amount of literature. Antonelli 
has described a case of dacryoadenitis of the inferior accessory lobules 
in a man aged twenty-five years. There was a small tumor, situated 
one centimetre up and out from the corneal limbus. 

DISEASES OF THE DRAINAGE APPARATUS. 

It is necessary to consider the affections of the puncta, canaliculi, 
sac, and duct. Diseases of these parts are characterized by an overflow 
of tears, a symptom which is known as epiphora. 

The Puncta may be congenitally absent or closed. Multiple puncta 
are sometimes seen. As a result of trachoma, or from cicatricial con¬ 
tractions following burns and other injuries, or from ulceration, the puncta 


DISEASES OF THE LACRIMAL APPARATUS. 


223 


may be misplaced. Drooping of the lower lid in facial paralysis causes 
the lower punctum to sag. Superficial occlusion of this also occurs in 
blepharitis marginalis. 

Hie treatment consists in the introduction of a sharp-pointed lacrimal 
probe. If the canaliculus also is occluded, it will be necessary to probe 
it or to slit it up to its junction with the sac. In cases of inversion or 
eversion of the punctum it will be necessary to remove the cause (en¬ 
tropion, ectropion, inflammatory thickening of the lid). 

The Canaliculi may be congenitally absent, in which case they are 
represented by furrows on the lid-margin, or occluded by cicatricial con¬ 
traction, foreign bodies, fungous growths, or tumors. Steffan and others 
have met with a supernumerary canaliculus of the lower eyelid. In case 
the canaliculi are absent, an attempt should be made to secure an open¬ 
ing directly into the sac, as described under the head of lacrimal opera¬ 
tions. In case a wound cuts a canaliculus across, the surgeon should 
attempt to pass a probe into the nasal duct and then insert a lacrimal 
style, which should be left in situ during the process of healing. Foreign 
bodies in the canaliculi are sometimes seen at the present time. The 
author has recently removed a birdshot from the superior canaliculus, 
where it had rested for nine years. Hairs, eyelashes, pieces of silk thread, 
and dacryoliths have been found in this part of the drainage apparatus. 
The author has met with one case in which the lower canaliculus was 
occupied by a growth of leptothrix, which formed a round, hard mass, 
producing epiphora and considerable inflammatory disturbance. The 
canaliculus, however, was not completely obstructed, since a stream of 
water from a syringe passed down the nasal duct. 

Any foreign body, such as a cilium or a piece of the beard of barley 
or wheat, if projecting, can be seized with forceps and removed. If not 
projecting, the canal should be opened to a small extent and the offend¬ 
ing substance should be picked out with forceps. Dacryoliths are to re¬ 
ceive the same treatment. Polypi have been occasionally found in the 
canaliculi. Incision of the canal and removal comprise the proper treat¬ 
ment. Stricture of the canaliculus, particularly of the lower, is often 
found at the nasal extremity of the canal. Its treatment will be con¬ 
sidered with that of stricture of the nasal duct. 

Mucocele of the Inferior Canaliculus has been described by 
Brady, of San Francisco. The dilated canal measured eleven by six milli¬ 
metres. It contained watery mucus, and was treated by destroying the lin¬ 
ing epithelium with an electrocautery. 

leptothrix Lacrimalis (Tear-stone) is a fungus which is rarely found 
in the canaliculi. It is much more frequent in the lower than in the 
upper canaliculus. The inner part of the lid, corresponding to the 
canaliculus, is red and swollen, with a tendency to ectropion, the appear¬ 
ance resembling that of a stye. The disease is unilateral. According 
to Kipp, it occurs in the proportion of 1 to 53,600 eye cases. The 


224 


MODERN OPHTHALMOLOGY. 


caruncle and plica semilunaris show a persistent conjunctivitis; and a 
tenacious, yellowish, creamy fluid exudes from the punctum. Noyes 
mentions a pumping or sucking movement in the dilated punctum. The 
fungous mass may be rounded and firm, feeling hard like a chalazion. 
The condition may be mistaken for hordeolum or for chronic dacryo¬ 
cystitis. From the latter it can easily be distinguished by the absence of 
distension of the lacrimal sac, and from the former by its chronic nature. 
Higgins met with a case of leptothrix which was mistaken for an epi¬ 
thelioma. Microscopic examination of the mass shows it to be composed 
of isolated, unbranched, straight, and very thin filamentous cells, similar 
to leptothrix buccalis found in the tartar of teeth. Leptothrix has the char¬ 
acteristic of secreting lime salts. When calcified, it forms a hard mass 
known as tear-stone. Up to 1874 the fungus found in these concretions was 
reported to have been leptothrix. Since that date streptothrix was found 
in all instances. Since 1894 actinomyces has been reported as present in 
such concretions. Evidently the subject demands further investigation. 
In the treatment of this disease pressure will cause the soft part to exude, 
but will not cure the condition. It will be necessary to slit the canaliculus 
and apply antiseptics to the portion distended by the mass. Here a mild 
solution of nitrate of silver will be useful. 

Lacrimal Actinomycosis.—Schroeder, in 1894, in a concretion removed 
from a canaliculus, found microscopic appearances typical of the ray- 
fungus. He believes that all previous cases of obstruction of a canaliculus 
by fungus were due to the development of actinomyces. Elschnig and 
Evetsky agree in this opinion, which the author knows to be incorrect. 
Actinomycosis has been found a few times producing obstruction of the 
canaliculi. The treatment for actinomycosis includes slitting of the canalic¬ 
ulus, removal of the mass, curettement of the walls of the distended canal, 
and the application of a bichlorid solution (1 to 1000). 

Inflammation of the Lacrimal Sac.—The lacrimal sac is subject to 
acute and chronic inflammation. The former is commonly known as 
abscess, the latter as blennorrhea of the sac. It would seem more rational 
to speak of inflammation of the sac as catarrhal or purulent. 

Etiology of Lacrimal Inflammations. —In the vast majority of 
cases inflammations of the sac and duct are due to the condition of the 
nasal chambers. The extension of catarrhal inflammation into the nasal 
duct causes swelling of the lining membrane, with a damming up of 
tears. Heat, moisture, and stagnation furnish favorable conditions for 
the multiplication of germs, with which the lacrimal secretion is always 
well supplied. Mucus and pus form within the sac and duct, and, 
although this pus does not cause severe inflammation when brought in 
contact with the conjunctiva, it does produce disastrous results in corneal 
wounds or in ulcers of the cornea. 

In a few cases periostitis with caries of the lacrimal bone, due to 
syphilis, produces a form of lacrimal stricture which is difficult to cure. 


DISEASES OF THE LACRIMAL APPARATUS. 


225 


Struma, by acting on the nasal mucous membrane, must be regarded as an 
etiologic factor. A slight nasal catarrh may cause lacrimation, photophobia, 
and redness, in eyes which are otherwise normal, the excretory passages being 
permeable. In such cases spraying of the nose with a mild antiseptic 
and the instillation into the conjunctiva of a few drops of zinc-cocain 
solution (zinc sulphate, gr. ss; cocain, gr. j; water, §j) will be followed 
by relief. The next attack of rhinitis will reproduce the symptoms. 

Certain cases of lacrimal obstruction are undoubtedly due to unskill¬ 
ful surgery. The habit, common among some practitioners, of slitting 
the canaliculus and passing probes upon every case showing epiphora, 
often results in the tearing of the membranous lining, the formation of 
cicatrices, and the production of infection. Such reckless treatment 
should be avoided. Occasionally a case of lacrimal obstruction is due 
to the lodgment of a piece of broken instrument, such as the point of a 
canaliculus knife, or the slipping of a style into the nasal duct. 

As regards the nasal disease, a great variety is presented, embracing 
hypertrophic and atrophic rhinitis, rliinoscleroma, the growth of polypi, 
nasal tuberculosis, malformation of the inferior turbinated body, the 
growth of exostoses, the presence of neoplasms in the antrum of the 
superior maxilla, etc. 

That a veritable trachomatous inflammation of the tear-sac exists 
has been demonstrated by Yincentiis, Cirincione, Kalt, Ivuhnt, and Kaehl- 
mann. Wernke, who made sections of ten tear-sacs removed from 
trachomatous patients, found in them the same pathologic changes that 
exist in the conjunctiva in trachoma. This fact helps to explain the 
etiology of acute dacryocystitis. It is necessary to state, however, that the 
correctness of these observations has been disputed. 

Lacrimal obstruction is common in the newborn. Stephenson found 
1.75 per cent, among 1538 out-patients of a children’s hospital. In many 
of these the history showed the presence of a discharge, either from or 
shortly after birth. The eye is generally not red, the cornea is clear, 
and it is exceptional to find a swelling behind the tendo oculi. A plug 
of mucus or muco-pus is present at the inner can thus. Pressure on the 
inner palpebral ligament causes a discharge to appear. That the etiology 
of this disease in the newborn is different from that of the adult is shown 
by the rarity of the evidence of syphilis, of nasal catarrh, or of bone 
disease. The cause is to be sought in the embryologic history of the 
sac and duct, obstruction in the newborn being due to delayed absorption 
of the material which exists during fetal life in the sac and duct, plus 
infection by bacteria. The bacteria found in the discharge from the sac 
and duct are numerous. They include pneumococcus, xerosis bacillus, 
staphylococcus pyogenes albus and aureus, bacillus coli communis, pneumo¬ 
bacillus, and bacillus foetidus ozasnas. 

Catarrhal Dacryocystitis.—This disease has generally passed the acute 
stage when the patient applies for treatment. In acute catarrhal dacryo- 


226 


MODERN OPHTHALMOLOGY. 


cystitis the chief symptom is epiphora. The patient is usually suffering 
with an acute rhinitis, and the involvement of the sac is the result of 
direct extension of the inflammatory process from the nasal mucous 
membrane. The conjunctiva is hyperemic. The skin of the lids and 
that over the sac is often excoriated from scalding tears and from the use of 
the handkerchief. Pressure on the sac causes the appearance of a slight 
mucous discharge. The disease is commonly bilateral. 

In cases of catarrhal inflammation which have become chronic there 
is often an accumulation of fluid in the sac, with a distension of its 
walls, forming above the tendo oculi a rounded, globular mass, known as 
mucocele. Pressure on the sac will cause the discharge of a thick, glairy 
mucus. While a mucocele is often small, it may attain enormous dimen¬ 
sions, as in a case recorded by Kenneth Scott, in which the distended 
sac reached from the inner angle of the eye to the angle of the mouth. 

Treatment. —In acute catarrhal dacryocystitis it will be necessary 
to treat the nose. The use of soothing sprays to the nasal mucous mem¬ 
brane will be beneficial. If there is great swelling of the membrane the 
application of suprarenal extract or of adrenalin solution will serve to 
reopen the nasal passage. This should be followed by the use of an 
oleaginous spray, either with or without menthol. 

The nasal treatment is to be followed by irrigation of the sac. For 
this purpose the lower punctum can be rapidly dilated to a size sufficient 
to admit the nozzle of the irrigator and an ounce or two of warm boric 
acid solution is caused to flow through the excretory channels. The 
application of very hot compresses to the region over the sac will be 
grateful to the patient and beneficial to the inflammation. In this con¬ 
dition cutting of the canaliculus is absolutely contra-indicated. The 
prognosis is favorable only when it is possible to treat the nasal chambers 
carefully and persistently. After the acute symptoms have subsided, the 
state of the refraction should be determined. 

In cases among the newborn pressure is to be applied daily over the 
sac, for the purpose of removing the secretion and opening the naso¬ 
lacrimal duct. Under this simple treatment most cases improve rapidly. 
Where this is insufficient, the surgeon should dilate the lower canaliculus 
and pass a probe, under general anesthesia. The canaliculus should not 
be cut. 

Suppurative Dacryocystitis.—As the result of an acute attack of in¬ 
flammation not ending in resolution, or from repeated attacks of catarrhal 
inflammation, the sac becomes filled with a purulent collection (Fig. 1, 
Plate VIII). The cause of most cases can be found to be a stricture of 
the naso-lacrimal duct. Suppurative dacryocystitis appears in two forms: 
the acute and the chronic. 

Acute Suppurative Inflammation of the Sac begins often with 
a chill. There is pain at the inner canthus. In the region of the sac 
a hard, brawny swelling appears, which closes the eyelids and often is 





PLATE VIII. 

Extarnal EiBaasaa of thB Eye. 

% 


. 

Fig, 1, 

SuppuratlvB Dacryocystitis, 



V -i • 



' *» ‘ if Jkf r ^ V 



Catarrhal Conjunctivitis. 


7V,.. l 







Fig. 2, 

Lacrimal Fistula. 






Fig. 4, 

Follicular Ccnjunctivitis. 

— jfljfePrv? 














Fig. B, 

Vernal Ccnjunctivitis 
iTaisal Type). 

" V ''' /’ 



^ ' *V ■ -ft 


m 




Fig, B. 




Tuberculosis of the Conjunctiva. 
(Eyre.) 

f*. { .yitt, JiS' 


1% 
















22 () 


■ 1 ,:, 'Vfnw 

cy-4 It 

is the chief u 

,3y 3 writ la .raaaBElCt.Ifl 

i ' 1 i.CiTO. 

i til 

an •*. ■ ■ '• i 

.is. and the h'volvenici!i 

direct 


f >: e inilau i/uiiory 

"nu :i i 


.•ojunctiva is hyperetru 

4 I1 4 

*$ ti ■ $. *« .** 

oitc-n c.Axoi'iab-d from .• ub 


- 

o t t'!m sac is the result of 
f' ,i i the nasal raucous 
XU: skin of the lids and 




•;.< app^areicc o a -'ight 

55 i -> >' I '' '.aetfhdHdb&^KisQ 'avtteitiqqaZ 

-Umunation • or nave become chronic there 
i- n :u acem .ujasio'i of fluid hi i :• sue., with a distension of its 
\i at iy- tbr (•ndoocul.i ;x ;> leu, globular mass, known as 

i i unv sac will b< discharge of a thick, gl 

While a r?m< • ie is often t may attain enormous dimen- 

< n e ease .rded hy.Kem an Scott, in which the distended 
from In' inner angle of the eye to he angle of the month. 

■ a'; went.—I. i> acute catarrhal dacryocystitis it will be necessary 

. Lose. The use of soothing sprays to the nasal mucous mem- 
) bene fie If there is great swelling of the membrane the 
„ *\jroot or <•? u> ! vnalin -olStfl'S •.« i.'l s-nv; to 

,J> ,gi^ .BcaoiiGB'iT 

.aLtt7'i:iau4if,uQQ'rttirnnibT. l'iiis •-houi<! ml lowed by the use of an 
r.,' . either with or without men V . 

atmeut is to be folk wed by its • n of the sac. For 
i lower }•• unci um can be rapidly di >:..d t a -u/e sulficient 

i • - .do of the irrigator and ail ounce ov two > i warm boric 

• caused; to flow through the oxcrctoij chaimt-Js. The 

hot compresses to ttu r *« over the -ac will be 
, i :•;* M if pm and beneficial to the iiiibniinfii-.*;i. \ t ibis con-j 
.!•..} w ‘canaliculus is absolutely contra-im.lh. the 

progm •• •• • when it is possible to treat the r , ’ >m b^rs 

o. . .\ftcr the acute symptoms .ssh ;• Vudvd,' the 

9 £rx , , - i .etltvtlunulaaU l£iiiiBtB3 

etr trbrj..-uytin: 3 IsmaVr • "® dt^clL lai. o. 

!vi ; ■ i>orn pressure i - ro be applied daily «nor the 

•, v '-oig the secretion and opening the naso- 
i treatment most cases improve rapidly, 
n should dilate the lower canaliculus 
•'« v u;hc-.-ia. Hie canaliculus should not 


CWPrfuii 
s t at 


sac, for t • 
lacrimal due- 1 
Where this 
and pass a probe, 
he cut. 


Suppurative Dacryocysi 

ihmmation not ending in r* .*••• 
in dam mat ion, the sac becomes 

VI11). The cause of u * 

•.B^Ubn l ctiiift‘ sUhlf? krtolubiBifJ?!' PI 111 ' " * ’ 

chronic. 

.Vcv.’i- SUPI’TJHATIYE InFI 
. • 1 here is pain at the inn; r 

a tni-d. i'lawuy 'swelling appear, win 


c result «.f an acute.attack of in¬ 
i'. repeated attacks of catarrhal 
■u puruhut collection (Fig. 1, 
«i: b found ro be a stricture of 
• ■. ■; ti* * wo forms: 

.rnirigY-rafq 

'in Sac beg! - ■ fvn with 
a!.- •• in the region of the sac 

c > ho eyelids and often is 


PLATE 8 






DISEASES OF THE LACRIMAL APPARATUS. 


227 


so extensive as to resemble orbital cellulitis. The greatest redness, how¬ 
ever, is found in the inner extremity of the swelling. The pain, caused 
by distension of the sac, is severe. After several days the swelling be¬ 
comes softer and diminishes in size. The inflammatory symptoms may 
gradually subside and may leave a chronic suppurative inflammation; or, 
as often happens, the abscess bursts through the sac and skin, thus form¬ 
ing a -fistula (Fig. 2, Plate VIII). Eepeated attacks of acute inflamma¬ 
tion occur until after the stricture has been opened and treated. 

Treatment .—In the beginning of an attack of acute inflammation of 
the sac the use of cool compresses will be beneficial. A saline cathartic 
should be given and the patient should be placed in bed. After the hard, 
brawny swelling has appeared, hot applications are preferable. Often the 
pain is so severe that anodynes are necessary. When the swelling begins 
to fluctuate, under an anesthetic the surgeon should slit the upper 
canaliculus and pass a series of probes through the stricture, dilating it 
ad maximum. The after-treatment consists in daily irrigation with an 
antiseptic solution (pyoktanin, 1 to 500; creolin, 1 to 20; silver nitrate, 
1 to 300) and probing until the discharge begins to lessen, after which 
the probing can be repeated at intervals of two or three days until re¬ 
covery takes place. In these cases it will be necessary to use the largest 
probes the canal will accept. As regards irrigation, astringents of many 
kinds have been tried. The hot-water treatment, combined with prob¬ 
ing, is probably as efficient as any method. 

Chronic Suppurative Inflammation of the Sac causes epiphora 
and often produces an obstinate conjunctivitis. Pressure on the sac leads 
to a discharge of pus through the canaliculi. This disease is caused 
usually by stricture of the nasal duct. The proper treatment is to dilate 
the stricture and use irrigation. 

Obstruction and Stricture of the Lacrimo-nasal Duct.—It is necessary 
to differentiate between obstruction and stricture. In the former, there 
is swelling and hypertrophy of the lining membrane of the duct, caused 
generally by the upward extension of the nasal disease (a swollen fold 
of the sac obstructing the lumen), or by the lodgment of a foreign body 
from above, or by eyestrain. Extension from below is common in ex¬ 
anthematous diseases, because of the accompanying inflammation of the 
naso-pharyngeal mucous membrane. It is also found in nasal polypi, 
and in hypertrophy of the inferior turbinated body. In these cases the 
change is limited to the lining membrane of the duct. The lodgment 
of cilia and other foreign bodies is probably more common than has been 
supposed. True anatomic stricture is rare. Its causes are predisposing 
and exciting. Among the former must be classed the various malforma¬ 
tions of the duct; and among the latter suppurative inflammation of 
the sac, the production of false passages by unskillful attempts at prob¬ 
ing, and the use of caustics. True stricture is occasionally due to an 
exostosis within the duct, the growth of a neoplasm situated within the 


228 


MODERN OPHTHALMOLOGY. 


nose or springing from the lining membrane of the antrum of Highmore, 
or the fracture of bones forming the duct. The cicatrization of a syph¬ 
ilitic or tuberculous ulcer, and the contraction attending atrophic rhinitis, 
are also causes of true stricture. In a few instances the whole lining 
membrane of the duct is converted into a fibrous cord. 

Symptoms. —The symptoms of obstruction and stricture are often 
masked. Epiphora may be the only external sign of disease. The pres¬ 
ence of mucocele or of blennorrhea of the sac generally indicates stricture, 
but may be due to simple obstruction. 

Diagnosis.— In making a diagnosis between simple obstruction and 
true stricture it will be necessary to employ the lacrimal syringe and 
probe and to take into consideration the condition of the nose. The 
surgeon should inject a few drops of a colored solution into the lower 
canaliculus, while the upper one is compressed. If the fluid passes into the 
nose, the duct is open. If it returns, there is either obstruction or true 
stricture. The diagnosis between these will require the passage of a probe 
through the rapidly dilated canaliculus. After enlarging the canaliculus, 
preferably the upper one, and passing the probe well into the sac, the 
syringe should be used again. If the solution now passes into the nose, 
the conclusion is that the obstruction has been overcome and the deeper 
use of probes will not be necessary. If the passage is not free, the probe 
must be used in the duct proper, and the obstruction or stricture located. 
The injection of a solution of the extract of the suprarenal gland into 
the duct will cause an obstruction to disappear, while having little or 
no effect on true stricture. 

Prognosis. —The prognosis of chronic affections of the duct must be 
guarded. Many of these cases will improve while under treatment, but will 
relapse. 

Treatment.— In all cases of obstruction to the passage of tears it 
will be advisable to begin with the examination and treatment of the nasal 
mucous membrane. The use of cocain or suprarenal extract will over¬ 
come swelling and enable the surgeon to inspect the condition of the in¬ 
ferior turbinated body and adjacent parts. Polypi should be removed; 
hypertrophies should be treated with the galvanocautery; and atrophic 
rhinitis will call for frequent cleansing of the passages. Simple rhinitis 
will improve under the use of Dobell's solution and the application of a 
spray of menthol in albolene. Adenoids should be removed and the con¬ 
dition of the whole naso-pharyngeal tract must be improved. 

After this has been done the sac and duct should be washed out daily 
with hot boric-acid solution. Errors of refraction should be corrected 
and the general condition of the patient should be looked after. 

Under this conservative treatment many cases will either result in 
a cure or their condition will be so much relieved that more radical treat¬ 
ment will not be required. There will remain, however, a certain per¬ 
centage of cases in which, in addition to the daily washing of the duct, 


DISEASES OF THE LACRIMAL APPARATUS. 


229 


it will be necessary to pass probes at intervals of three or four days. The 
probing should be done through the dilated and uncut canaliculus. By 
patience, the surgeon will generally succeed in passing the probe without 
cutting, the canaliculus. If there are cicatricial bands, it will be safer 
to cut them with a curved canaliculus knife (passed through the dilated 
canaliculus) than to risk the formation of a false passage by the use of the 
probe. 

Immediately after cutting the resisting bands the probe is to be passed. 
When the obstruction is located at the junction of the sac and duct, or 
is in any part of the upper half of the duct, the probe of Snellen (Fig. 
197) is preferred. This instrument has a bulbous tip and is made on 
the principle of the wedge, thus giving the greatest dilation at the place 
where contraction is often found, viz.: the junction of the sac and duct. 
The probe should remain in position for ten minutes, when it is to be 
withdrawn and the duct is to be washed with boric-acid solution. The 
manipulation necessary to cut the fibrous bands, without cutting the 
canaliculus, will be explained in the latter part of this chapter. 

In case a true stricture exists, the treatment mentioned above will 
show its site and resistance. If an exostosis is found in the lower part 
of the duct, an attempt should be made to tap the middle nasal meatus, 
as is explained under lacrimal operations. Such a condition, however, is 
rare, and generally treatment gives poor results. In ordinary cases of 
stricture some force is required to pass the probe, but it must be intelligent 
force; and no surgeon should operate on the living who has not repeatedly 
practiced on the dead. It may happen that the stricture is located at 
the lower end of the duct; if so, the use of (Theobald’s) long probes will 
be necessary, and the canaliculus should first be cut. Whenever cutting 
of the canaliculus is required, it will be best to incise it in only part of 
its extent. Often a cut one-sixth of an inch in length will suffice. Such 
a short incision, while permitting the use of the probe, will not entirely 
destroy the function of the canal. 

Cases occur in which, although probing and irrigation are easily ac¬ 
complished, troublesome epiphora persists. In this event search should 
be made for pathologic conditions within the nose, causing a valve-like 
fold of mucous membrane to occlude the duct. 

In the treatment of lacrimal stricture by probes only the metal in¬ 
struments are now used. The method of Gensoul, who passed the probes 
from the nasal end of the duct, is not now in use. It is possible, however, 
to probe the lower half of the canal by this method, and cases may be seen 
in which this procedure will be of value. In operating from above, it 
may happen that the surgeon will be in doubt whether the probe has 
passed into the nasal fossa. In such an event, the nasal speculum should 
be introduced, the parts should be illuminated, and another probe should be 
passed between the inferior turbinated bone and the outer nasal wall until 
it touches the instrument in the lacrimal duct. 


230 


MODERN OPHTHALMOLOGY. 


In cases of true stricture which do not yield to the plan of treatment 
here outlined, the surgeon can resort to one of five procedures: 1. The 
canaliculus can he slit in its entire length and probes of large calibre used. 

2. A style can be introduced and worn for several months, with the ex- 
pectation of producing absorption of the stricture walls. 3. The surgeon 
can excise the walls of the stricture by chiseling away the anterior osseous 
wall, after which a flexible catheter can be left in the duct until cicatriza¬ 
tion is complete. 4. The stricture may be treated by electrolysis. 5. 
The lacrimal sac and gland can be excised. 

1. Although the first method has the sanction of some eminent names, 
it is not to be looked on with favor. The forcing of large probes through 
the lacrimo-nasal duct often gives immediate improvement, which, after 
a few months, is followed by the formation of a stricture at the point 
where the canaliculus joins the duct; or the lining membrane of the duct 
may be converted into a firm cord of fibrous tissue, extending from the 
sac to the nasal chamber. This unfortunate result frequently occurs. 
If the canal remains open, the patient finds that, whenever he blows his 
nose, air and mucus are forced upward into the conjunctiva, and thus the 
eye is exposed to infection from this source. 

2. The introduction and wearing of a style is a very old method of 
treatment and sometimes is an efficient one. Numerous substances have 
been used for this purpose. Probably a piece of large silver wire is as 
good as any. Hollow styles are also in use. An important point is to 
provide the style with a flange which shall be long enough to prevent the 
instrument slipping down into the duct. If this accident occurs, and 
efforts at removal are unsuccessful, a silver style can be destroyed by the cor¬ 
roding effect of weak solutions of iodin injected repeatedly into the duct. 
The style can be removed from time to time and the duct examined to 
determine whether its lumen is increasing. Generally a stymie must be 
worn for several months. Weidler has recorded a case in which orbital 
cellulitis followed slitting of the canaliculus and the use of a leaden style. 

3. Excision of the walls of the stricture, particularly when the ob¬ 
struction is osseous, is a method of treatment which has occurred to the 
author as having a possible value in a few rare cases which do not yield 
to less heroic methods. After removal of all offending tissue, the opera¬ 
tion having been made under aseptic precautions, it will be advisable to 
place a style or possibly a piece of rubber catheter in the duct, removing 
and reintroducing it from time to time, until cicatrization is complete. 

4. Electrolysis, as a method of treatment of stricture of the lacrimal 
passages, was originally proposed and used by Tripier and Desmarres 
about thirty years ago. The latter pronounced against the method, which 
was afterward tried by many ophthalmologists and abandoned by most 
of them. Kecently Lagrange, Chabaneix, and Fournier have made a com¬ 
plete study of the subject. They regard this form of treatment as valu¬ 
able. Lagrange believes that electrolysis will effect a cure of lacrimal 


DISEASES OF THE LACRIMAL APPARATUS. 


231 


stricture rapidly, harmlessly, and painlessly. That part of the probe lying 
in the canaliculus must be insulated; otherwise this portion of the excretory 
apparatus will receive the full force of the electrolytic action, and oblitera¬ 
tion of the canaliculus will result. The current must be a weak one, in¬ 
sufficient to produce a caustic effect on the mucous lining of the nasal 
duct. The technique of the procedure will he discussed in the latter part 
of this chapter. Mial has recently pronounced in favor of electrolysis, 
which, he says, opens the lacrimal passages “speedily, painlessly, and with¬ 
out hemorrhage, and, furthermore, is antiseptic in its action.” 

5. Excision of the sac and gland can he practiced, as will he explained 
in the latter part of this chapter. 

Fistula of the Lacrimal Sac, which has rarely been seen as a congenital 
condition, generally follows the breaking of an abscess, which opens below 
the tenclo oculi (Fig. 2, Plate VIII). The fistula may open directly into 
the sac or may run a tortuous course. The edges of the opening are often 
hard, thickened, and ulcerated, and present exuberant granulations, and a 
discharge of tears and muco-pus. In some cases caries of the bone is present. 
The presence of a fistula in this location points to the existence of a stric¬ 
ture, which must be treated. Fistula is artificially produced when the sur¬ 
geon incises the anterior wall of the sac to evacuate pus in suppurative 
dacryocystitis. In treating fistula it will be necessary to slit the canaliculus 
and pass the probes through the stricture. This treatment, combined 
with antiseptic injections, will cure nearly all cases. If, after the patency 
of the duct has been restored, the fistula refuses to close, a red-hot wire 
can be passed into it. The closure of the fistula is not to be attempted 
until after the stricture of the nasal duct has been removed. In these 
cases the presence of the fistulous tract is a safeguard against another 
attack of acute dacryocystitis. 


LACRIMAL OPERATIONS. 

I. Operations on the Lacrimal Gland are divisible into (1) those on the 
orbital lacrimal gland, and (2) operations on the palpebral gland. 

1. Extirpation of the Orbital Portion is indicated both in health 
and in disease. According to C. R. Holmes, the normal gland and diseased 
sac are to be removed:— 

1. In troublesome and otherwise incurable epiphora. 

2. In cases where operations involving the opening of the globe must be 
performed and there is not sufficient time to apply other treatment. 

3. In patients who lack the time for, or are unable to endure, probing. 

The diseased gland should be removed:— 

1. In adenoma which does not respond to other treatment. 

2. In adenosarcoma and carcinoma. 


232 


MODERN OPHTHALMOLOGY. 


Technique .—The field of operation having been shaved and made 
surgically clean, under general anesthesia a curved incision, four centi¬ 
metres in length, is made along the base of the orbit over the site of the 
gland. For cosmetic reasons the cut should be made in the field of the 
eyebrow. The lower end of the incision should reach to the insertion 
of the outer canthal ligament. The tissues are separated down to the 
bone, the wound being opened by retractors. The connective tissue is 
incised over the gland, which is brought forward by forceps and shelled 
out of its bed. In operating upon a diseased gland the surgeon should 
be certain to remove all indurated, swollen, and diseased tissue. The 
lips of the wound are sutured and a dry gauze dressing and bandage are 
applied. Healing is uneventful. 



Fig. 194.—Probes passed into the eanaliculi to show their direction. 

(Author.) 

(Original drawing by Dr. R. W. Mills.) 

2. Excision of tiie Palpebral Gland is indicated in troublesome 
epiphora, not curable by other means, and in neoplasms. A local anes¬ 
thetic is used. The surgeon seizes the everted upper lid, draws it upward 
and away from the globe, and makes an incision through the conjunctiva. 
The gland is held with forceps and excised. Owing to the glandular 
character of the mass, removal of all parts of it is difficult. The wound 
need not be stitched. This operation cuts the efferent ducts of the orbital 
lacrimal gland. 

Obliteration or the Excretory Ducts by the galvanocautery is 
practiced by Bettremieux. ltepeated cauterizations are necessary. 

The Effect of These Operations is to diminish epiphora when the nor¬ 
mal tissues are removed, and to remove deformity and exophthalmos when 
the diseased orbital gland is excised. Except in the presence of atrophy, 
the conjunctiva does not become dry as a result of these procedures, for 


DISEASES OF THE LACRIMAL APPARATUS. 


233 


the reason that a sufficient amount of lacrimal fluid is secreted by the 
accessory glands, which are scattered through the lids. 

II. Operations on the Excretory Apparatus.—These are the follow¬ 
ing :— 


1. Opening of a closed punctum. 6. Opening of naso-lacrimal stricture. 

2. Syringing of the excretory apparatus. 7. Opening of an obliterated nasal canal. 

3. Dilation of the canaliculus. 8. Insertion of a lacrimal style. 

4. Cutting of the canaliculus. 9. Obliteration of part of the apparatus. 

5. Excision of the lacrimal sac. 10. Electrolytic treatment of stricture. 

11. Incision of the anterior wall of the lacrimal sac. 

1. The Punctum can be Opened by drawing the lid outward from 
the globe and steadying it by traction made toward the outer canthus. Then 
a needle or conical probe is passed perpendicularly to the lid-margin 
for one millimetre; it is then turned to a horizontal direction, and passed 
into the canaliculus. The natural direction of the canals is shown in 
Pig. 194. This procedure is necessary as a preliminary step to syringing the 
duct and to the passage of probes without slitting the canaliculus. 



Fig. 195.—Lacrimal syringe. (McFarlan.) 


2. Stringing the Excretory Apparatus is accomplished by pass¬ 
ing the tip of Anel’s, Meyer’s, or McFarlan’s instrument into the punctum 
and canaliculus. The fluid is then discharged and the effect is noted. 
If the fluid returns, it is evidence of a stricture in some part of the ex¬ 
cretory apparatus. If the fluid passes into the nose, the canals are per¬ 
vious. If the fluid passes downward into the naso-lacrimal duct, care 
should be taken not to tear the lining membrane. Syringing is valuable 
(1) as a diagnostic measure and (2) for therapeutic reasons. In the latter 
instance lavage of the duct is of great value in the treatment of chronic 
purulent inflammation. The apparatus which is shown in Fig. 196 is of 
value. It consists of a reservoir, a rubber tube, and a probe-pointed can- 
nula. 

3. Dilation of the Canaliculus is necessary whenever the surgeon 
wishes to pass a probe into the duct without cutting the canaliculus. The 
latter operation is resorted to in many cases where the former would 
suffice. The canaliculus can be dilated easily by passing probes of in¬ 
creasing size. Often an annoying epiphora will disappear after this little 
operation. 






234 


MODERN OPHTHALMOLOGY. 


4. Cutting of the Canaliculus is necessary in the removal of for¬ 
eign bodies, fungous growths, or calcareous masses; in eversions of the 
punctum causing epiphora; as preparatory to syringing the deeper parts 
of the excretory apparatus; and in case the passage of large probes is re¬ 
quired. It is indicated in cases where the discharge from the sac is dis¬ 
tinctly purulent, where the parts around the sac are red and tender, and 
where an abscess or fistula exists. 

The operation requires the probe-pointed canaliculus knife of Weber 
or that of Stilling. The surgeon, standing behind the patient and sup¬ 
porting his head, passes the beak of the knife into the punctum. The 
lid is stretched and steadied by traction made on the outer cantlius. The 
knife, with edge turned slightly toward the globe, is then pushed into the 
canaliculus and is made to pass from the horizontal to the vertical position. 
This movement cuts the wall of the canal. There is slight bleeding, and 



Fig. 196.—Apparatus for lavage of the naso-lacrimal duct. 

(Author.) 

no dressing is necessary. The wound must be kept open by daily prob¬ 
ing, as otherwise it will heal. 

5. Excision of the Lacrimal Sac has been done for these condi¬ 
tions : chronic dacryocystoblennorrhea, chronic stricture with discharge, 
occlusion of the nasal canal, chronic lacrimal fistula, and large mucocele. 
In addition to these, removal of the sac may be advisable where, in chronic 
inflammation, the patient’s circumstances do not permit the long course 
of treatment needed to effect a cure, and in cases in which an operation 
requiring the opening of the eyeball is imperative. Excision of the sac 
should not be undertaken lightly. 

Technique .—The field of operation and adjacent parts having been 
made surgically clean, the nasal cavity is plugged with gauze to prevent 
the flow of blood into the pharynx. The sac, duet, and nose should have 
been previously irrigated. A thick solution of starch, colored with iodin, 
is injected into the sac to render its outlines clear (C. R. Holmes). In 








DISEASES OF THE LACRIMAL APPARATUS. 


235 


order to prevent infection, some operators obliterate the canalicnli by the 
galvanic cautery. This procedure also prevents the establishment of a 
fistula. An incision is made, beginning at a point just below the lower 
border of the middle of the tendo oculi and extending one inch downward 
and outward. There is likely to be free hemorrhage in this operation and 
it will he necessary to clamp several small arteries. The skin is now dis¬ 
sected carefully from the sac, which, if possible, is to he excised unopened. 
The lips of the wound are held apart, and, by means of scissors and a 
blunt chisel, the sac is separated from its bony bed. It is then excised 
close to the nasal duct and the duct and bed of the sac are thoroughly 
curetted. The surgeon should be sure to remove all parts of the sac, as 
otherwise the suppuration will return. Great care is necessary to prevent 
inundation of the wound and globe with the contents of the sac. Such 
material is highly infective, and, in the presence of a corneal wound or 
ulcer, may cause disastrous inflammation. The wound is to be closed 
with catgut sutures. A compress bandage with heavy tampons is applied 
over the operated area. 

6. Catheterism (Probikg) of the Nasal Duct is necessary in 
stricture. It is a painful operation and one that requires great skill. It 



is perhaps necessary to say that the beginner should practice passing 
probes on the cadaver before employing them on the living. The usual 
direction of the nasal duct is downward, backward, and outward, but the 
variations are many. The choice of a probe is important. The old Bow¬ 
man instrument should never be used. Only those probes bearing an 
olive-shaped tip are to be employed. Of these the author prefers that 
of Snellen (Fig. 197). It combines the proper tip with the wedge shape, 
and thus possesses two advantages; the tip cannot well make a false 
passage, and the greatest dilation is at the junction of the sac and duct 
—a point where stricture is often located. After using Snellen’s probes 
a few times, the instruments of Theobald can be employed. Their chief 
advantages lie in their length and in the gradual increase in size. The 
author believes in the use of the largest probes compatible with the in¬ 
tegrity of the tissues, but he does not believe in the forcing of large probes 
into the duct. 

Technique .—The canaliculus having been widely dilated or cut, and 
the sac emptied by pressure, the surgeon, standing behind the patient, 
passes the probe horizontally into the canaliculus until the lacrimal bone 
is felt. The probe is then to be withdrawn one millimetre and placed ver¬ 
tically; then it is passed downward into the duct. Gentle pressure is 


236 


MODERN OPHTHALMOLOGY. 


used, and, if an obstruction is met, the probe is withdrawn, its curve is 
altered, and another attempt is made to pass it. At the lower end of 
the duet an obstruction is often felt, which means that the probe is im¬ 
pinging on the osseous wall of the canal. In such a case the probe is to 
be withdrawn slightly, and its direction slightly changed. Up to this 
point the concavity of the probe has faced outward, but to pass it into 
the nasal meatus it will be necessary to turn it until the concavity faces 
directly forward, or even forward and- toward the opposite side. The com¬ 
plete passage of the probe will be evidenced by the removal of the im¬ 
pediment and by the fact that it passes from five to ten millimetres farther. 
The patient will complain of pain when the tip of the instrument strikes 
the lining membrane of the floor of the nasal meatus. 

Many impediments may be met. The most frequent one arises from 
the point of the probe becoming entangled in a fold of mucous membrane of 
the sac at the time the instrument is moved from the horizontal to the 
vertical position. To use force under such circumstances is to cause a 
false passage. When such resistance is met, the probe should be with¬ 
drawn to a slight extent and another attempt should be made to enter 
it. The tearing of the lining membrane of the duct is not such a trifling 
accident as might be supposed, since it not only may cause irremediable 
stricture, but it opens the door to infection and in rare cases has caused 
phlegmonous inflammation, orbital cellulitis, loss of vision from optic- 
nerve atrophy, and even meningitis. The probe may slide readily over 
the first obstruction, but its point impinges on the lateral wall of the 
duct. In such a case the curve of the instrument must be changed or its 
direction altered. If, after two or three attempts, it fails to pass, the 
best procedure is not to continue farther at this sitting, but to dilate ad 
maximum the part of the duct which has been opened. This is done by 
rapidly increasing the size of the probe, which is to be left in situ for 
from fifteen to thirty minutes. A few days later an attempt can be made 
to finish the work. 

A method of treating lacrimal stricture which aims to preserve the 
canaliculus intact has been devised by Caldwell, who, after passing a small 
probe through the upper canaliculus, stretches the skin at the outer 
canthus so as to render the point of the probe prominent. The surgeon 
then cuts down upon the probe and into the sac. A suture is then taken 
from the inner lip of the wound, including the sac, and left long for future 
use. Through this incision probes can be passed, the duct can be irrigated, 
and the site of the stricture is immediately located. When found, the 
stricture is cut with the probe-pointed canaliculus knife. Then the dila¬ 
tion is continued up to a No. 12 probe, if the duct will admit it. Closure 
of the wound in the sac can be prevented by the introduction of a piece 
of rubber drainage tube, until such time as the obstruction in the duct 
has been overcome. Then the lips of the wound are freshened and united 
with catgut sutures. Caldwell’s probe (Fig. 198) consists of a staff, 11 


DISEASES OF THE LACRIMAL APPARATUS. 


237 


centimetres long, with a bullet-shaped tip, 1 centimetre long, on each 
end. The tips are graded in size, each unit representing 2.5 millimetres 
of diameter. 

7. Opening an Obliterated Nasal Canal can be attempted in 
those cases in which a bony stricture exists, due to exostosis, fracture, 
or caries. It is also indicated in those firm, fibrous strictures which have 
resisted ordinary methods of treatment. In two cases of bony closure, 
operated on by Caldwell, the nasal duct was successfully tapped in the 
middle nasal meatus, by means of an electric burr, after passing the probe 
into the duct as far as the site of the stricture. The operation requires 
careful measurements and exact anatomic knowledge. If this procedure 
fails, the surgeon can obliterate or excise the sac and remove the lacrimal 
gland; or the excision of the stricture can be attempted. The latter will 
require general anesthesia, and a scar will be left on the face. The space 
beneath the inferior turbinated hone, and that between the middle and 
inferior turbinated, is to be packed with absorbent cotton or gauze, to 
prevent the flow of blood into the pharynx. After passing a probe down 
to the point of stricture, the surgeon incises the soft parts, turns them 
back, separates the periosteum from the bone overlying the stricture, and 



then chisels away the osseous wall. The exostosis is removed, and a 
small style is passed through the naso-lacrimal duct to a point below the 
site of the stricture. The soft parts are then united by fine catgut sutures. 

8. Insertion of the Lacrimal Style. —The style is of use chiefly 
in those patients who live far from a surgeon or who can return for 
treatment only at long intervals. Gold, silver, lead, platinum, and rubber 
are among the materials most frequently used. An excellent style is one 
made of No. 25 platinum wire. The tubular styles are useless, becoming 
clogged with dust and mucus. Guiata employs the decalcified bone of 
a turtle’s thigh as a style, and reports many cases cured. Whatever the 
material used, the style is to be provided with an elbow sufficiently long 
to prevent the instrument from slipping into the duct. The lower cana¬ 
liculus having been cut and the duct having been dilated by probes, the 
style is given the same curve as that of the probe, and is introduced. 
When properly inserted, the instrument cannot be seen. Slight discom¬ 
fort is caused for a few hours by its presence, but soon the patient ceases 
to note this. It should be removed monthly and the surgeon should 
observe the effect produced. Absorption of the stricture walls generally is 
complete in three or four months. The instrument can then be discarded. 
In many cases, however, the epiphora returns. 




238 


MODERN OPHTHALMOLOGY. 


9. Obliteration of Part of the Lacrimal Apparatus. —The 
puncta and canaliculi may be obliterated by the use of a galvanocautery 
or by a ligature. The operation is performed for the purpose of preventing 
secretion from an inflamed lacrimal sac reaching the globe and thus 
possibly causing infection in accidental injuries of the cornea and in 
operations requiring opening of the globe. Obliteration of any part of 
the lacrimal apparatus is best done by means of the galvanocautery. 

10. Electrolytic Treatment of Stricture. —In the use of elec¬ 
trolysis Lagrange employs from 2 to 4 milliamperes for two or three 
minutes, the seances being repeated every third or fourth day. A rheostat 
is used to prevent too high a degree of electrolytic action. The sound 
is to be insulated for a short distance, corresponding to the extent of the 
canaliculus. This constitutes the negative pole; the positive pole can 
be placed on the nape of the neck, or, as Gorecki advises, it can be in¬ 
troduced into the nostril of the same side. This treatment is to be used 
in conjunction with probing. 

11. Incision of the Anterior Wall of the Lacrimal Sac is a 
simple operation which is best done with a Beer knife, and does not re¬ 
quire detailed description. The operation is indicated in phlegmonous 
inflammation, in mucocele, and as a prophylactic measure in corneal ulcers, 
injuries, or operations where chronic dacryocystitis exists. Extensive 
opening of the sac is necessary in the removal of foreign bodies and as 
a step in the operation of obliteration. 


CHAPTER VII. 


DISEASES OF THE CONJUNCTIVA. 

The conjunctiva is liable to congenital anomalies, tumors, inflam¬ 
mations, hypertrophies, degenerations, atrophy, tubercular and leprous 
infections, and injuries. These affections will be considered in the order 
mentioned. The conjunctiva is often involved in the cutaneous diseases of 
the lids; and, from its direct connection with the nasal mucous membrane 
via the lacrimo-nasal duct, it is influenced by morbid conditions of the nose 
and throat. Pathogenic microorganisms can be carried to the conjunc¬ 
tiva in many other ways: by the hands, towels, handkerchiefs, by water 
in swimming-pools, by dust, and by flies and other insects. Normally 
the conjunctiva always contains bacteria, twenty-eight varieties having 
been isolated by Eyre. Of these the staphylococcus epidermidis albus, as 
Randolph has shown, is found so frequently that it must be regarded 
as a regular inhabitant of the conjunctiva. Fortunately this coccus possesses 
but slight pathogenic properties. It is probable that bacteria which are 
non-pathogenic in the normal conjunctiva may become harmful when 
this membrane is injured or irritated. The temperature of the con¬ 
junctiva, which is normally 96° F. (Silex), is increased in disease. On 
account of the source of its blood-supply, the conjunctiva is involved 
to a certain extent in inflammation of the cornea, iris, and ciliary body. 
Conjunctival diseases are common, forming about 30 per cent, of oph¬ 
thalmic cases in this country. Their frequency varies much with climate, 
latitude, and race, and may range from 10 to 90 per cent. 

CONGENITAL ANOMALIES. 

A few cases of congenital thickening of the conjunctiva, resembling 
pterygia and extending between the fissures of the lid, have been ob¬ 
served. The dermoid tumor, which is congenital, will be considered 
elsewhere. In cryptophthalmos the conjunctival sac is absent. 

TUMORS OF THE CONJUNCTIVA. 

Benign and malignant growths appear in the conjunctiva. Among 
the former are dermoids, lipomata, fibromata, polypi and granulation 
tumors, vascular tumors, osteomata, cysticerci, and lymphectasite. The 
malignant growths are sarcomata and epitheliomata. The diagnosis of 
the nature of a conjunctival tumor may be difficult or impossible until 
after a microscopic examination. 


( 239 ) 


240 


MODERN OPHTHALMOLOGY. 


BENIGN TUMORS. 

Dermoid Tumor.—The dermoid tumor, which is a congenital growth, 
generally is a flat, solid mass of a reddish or whitish color. It is situated 
partly in the conjunctiva, partly in the cornea, and is anchored to the 
latter. Often the surface is dry and is covered with downy hairs. Fre¬ 
quently other congenital anomalies are present. Demours met with a 
dermoid located on the caruncle, in which the same eye showed an 
eccentric pupil. Wardrop described a dermoid of the conjunctiva from 
which twelve long hairs grew and hung over the cheek, as in the case 
shown in Fig. 199. In Wardrop’s case the hairs did not appear until 
the sixteenth year, when the beard began to grow. The tumor is prac¬ 
tically an island of skin planted on the eyeball. Histologically it pre¬ 
sents a connective-tissue stroma, covered with epidermis and containing hair- 
follicles, sweat-glands, and sebaceous glands (Fig. 200). If thoroughly 
removed it does not return. 



Fig. 199.—Dermoid tumor of the conjunctiva. 

(Von Ammon.) 

Subconjunctival Lipoma.—Another congenital growth is the lipoma, 
which may be single or multiple. This tumor is often quiescent until 
the time of puberty, when it begins to grow. It is covered by con¬ 
junctiva, is movable upon the eyeball, presents a yellowish color, and 
generally forms only one tumor-mass, but exceptionally is lobulated. 
It may become two centimetres in breadth, but is generally half this 
size. Sometimes lipomata arise from the orbital fat and cause the con¬ 
junctiva to bulge near the lacrimal gland and between the insertions 
of the recti muscles. Usually this is the only growth present, but Fuchs 
shows an illustration of a subconjunctival lipoma and a corneal dermoid 
in the same eye of a girl aged thirteen years; and Burnett, under the 
name dermolipomata, describes tumors containing both fat and skin 
elements. These tumors do not return after removal. 

Fibroma is rarely found in the conjunctiva, where it forms a broad, 
flat growth occupying usually the upper cul-de-sac. Microscopically it is 
composed of interlacing strands of fibrous connective tissue with few 
vessels and with practically no interfibrillary substance. These tumors 




diseases of the conjunctiva. 


241 


do not recur. They are supposed to begin as polypoid growths which 
in time are changed into simple connective-tissue masses. 

Myxoma has been observed very rarely in the conjunctiva. 

Polypi, Papillomata, and Granulation Tumors can he described to¬ 
gether. Polypi are soft or semisolid pedunculated tumors, covered by 
mucous membrane, and generally spring from the fornix. Usually mul¬ 
tiple, small, and hidden, they may grow and project between the lids. 
They may become ulcerated. They are usually caused by the irritation 
of a retained foreign body. When this is removed and the polypus is 
snipped off, a cure readily follows. Histologically they are small fibro¬ 
mata pushing the conjunctiva in front of them. Papillomata spring 



Fig. 200.—Microscopic section of a conjunctival dermoid tumor. 

(Author.) 

(Original drawing by Dr. Carl Fisch.) 

1 , 2, Epithelium of the conjunctiva. 3 , 4, Round-cell infiltration. 5, 6 , Connective 
tissue. 7, 8 , Sebaceous glands. 9 , Hair-follicle with sebaceous gland. 

from the caruncle. They are composed of connective tissue and blood¬ 
vessels, and bleed easily. They are not smooth like the polypi, but 
present a papillary, nodulated, or cauliflower-like appearance. They have 
a broad base, and are likely to recur. In rare instances they undergo 
carcinomatous degeneration. Grannlomata resemble polypi, but differ 
in this respect: they are not covered by conjunctiva, but are naked 
granulation masses. They arise from surfaces made raw either by ulcera¬ 
tion or by operation. They are often found after an operation for stra¬ 
bismus, enucleation, or chalazion. They cause bloody tears and many 
of the miraculous instances of bloody lacrimation can be thus explained. 
They are soft, irregular on the surface, but often become smooth from 

16 






242 


MODERN OPHTHALMOLOGY. 


friction. They may expand so as to cover one-half the inner surface 
of the upper lid. They should be removed by the scissors. The base should 
be cauterized. If this be thoroughly done, they do not return. 

Vascular Tumors.—Primary angiomata of the conjunctiva are very 
rare. They are congenital and increase in size after birth. They usually 
spring from the caruncle. Reik met with a cavernous angioma grow¬ 
ing from the bulbar conjunctiva. The large angiomas found about the 
eye generally spring from the eyelid or from the depths of the orbit. They 
form dark jDurple-red tumors. Microscopically they are composed of loose 
connective tissue with many small areolar spaces and numerous blood¬ 
vessels. The large blood-spaces are traversed by connective tissue and are 
lined with endothelium. Angiomas should be excised. The author has 
seen one case of angioma of the retina involving also the tissues of the 
orbit and side of the face. Enlarged tortuous veins in the conjunctiva 
are often present in glaucoma and in the eyes of alcoholics. True varix 
is sometimes seen as a blue mass of veins, pyramidal in shape, the apex 
pointing toward the cornea. Phleboliths have been found in these 



Fig. 201/—Polypi of the conjunctiva. (De Beck.) 

The outlines of the cornea and the lids are shown by dotted lines. The upper lid is everted, 
and a foreign body, a piece of straw, is seen in the upper fornix. 

masses. Pressure will empty these tumors, and ligation is the proper 
treatment. 

Burnett has recorded an interesting case of hematoma of the con¬ 
junctiva. The tumor was the size of a pigeon’s egg. 

Osteoma of the conjunctiva is an unusual disease of which examples 
have been recorded by Critchett, Snell, Heustis, Oliver, and others. In the 
case treated by Heustis the piece of bone measured 7 by 4 millimetres. It 
was situated near the outer canthus. His patient was twenty-three years 
of age. Osteomata and fibro-osteomata of the conjunctiva are supposed 
to be congenital growths. They have been found in very young children. 
They should be excised. 

Cysts of the conjunctiva are not rare. They appear usually in the 
lower lid as small vesicles of a straw color. They can be incised and 
curetted. The cysts found in the ocular conjunctiva arise generally from 
dilated lymph-vessels. 

Subconjunctival Cysts. —A rare form of cyst is that which is 
due to enlargement of the acinotubular glands of Krause, which are 
most numerous in the forniees and in the caruncle. Gelatinous cysts 



DISEASES OF THE CONJUNCTIVA. 


243 


situated beneath the ocular conjunctiva have been described by Fehr. 
The subconjunctival cyst shown in Fig. 202 was immobile and tense. It 
developed beneath an overlying pterygium. When incised, a thin, straw- 
colored fluid escaped. The growth, which was of eight years’ duration, 
filled the space between the cornea and the inner canthus. Microscopic 
examination showed a tissue richly supplied with spaces, which were 
lined with layers of epithelial cells resting upon a dense, thin, fibrous 
structure. The general appearance was that of dermal structure, al¬ 
though sebaceous glands and hair-follicles were absent. 

Cysticekcus. —Large cvsts beneath the mucous membrane arise 
from the cysticereus cellulosae. They are generally found in children 
or young subjects. Early in its history the cyst is transparent and 
the head of the animal may be seen. The overlying conjunctiva becomes 
inflamed and opaque, thus making the diagnosis difficult. The most 
common site for such a cyst is beneath the ocular conjunctiva. Earely 



Fig. 202.—Subconjunctival cyst. (Author.) 


is it found in the fornix or palpebral conjunctiva. Juda has recorded 
an interesting case of cyst of this character in a boy six years old. The 
cyst occupied the space between the cornea and caruncle. Cysticereus 
is rare in all countries except Iceland, Finland, northern Germany, and 
Manitoba. In northern Germany among 80,000 patients von Graefe saw 
8 cases in the deeper parts of the eye, 3 in the anterior chamber, 5 
beneath the conjunctiva, and 1 in the orbit. Few cases of cysticereus 
of any part of the eye have been seen in the L nited States. The treat¬ 
ment consists in incision of the conjunctiva and removal of the sac. 

lymphectasiae.—The lymphectasiae result from dilation of the lymph- 
channels of the conjunctiva. The lymphatics appear as small trans¬ 
parent beads, generally placed in the palpebral fissure, midway between 
the cornea and canthus. Leber has reported one case in which the 
lymph was periodically mixed with the coloring matter of the blood 
(lymphectasia menorrhagica). The lymphectasiae cause little or no 
trouble. If treatment is required, they may be opened or excised. 



244 


MODERN OPHTHALMOLOGY. 


MALIGNANT TUMORS OF THE CONJUNCTIVA. 

Sarcoma.—A sarcoma of this region is either a leucosarcoma, with 
or without hematogenous pigmentation, or a melanosarcoma. The former 



Fig. 203.—Microscopic section of an epibulbar leucosarcoma with 
hematogenous pigmentation. (Kerschbaumer.) 

develops from the conjunctival or episcleral vessels, the latter from a 
nasvus pigmentosus. The first sign of the tumor is a growth of the adven¬ 
titial cells of the conjunctival vessels. When formed, the tumor-mass is 



Fig. 204.—Antero-posterior section of primary sarcoma of the conjunctiva. 

(Author.) 

The neoplasm extends over the cornea ; the anterior chamber is obliterated. The detachment 

of the retina is accidental. 


rich in vessels. The stroma shows spindle-shaped, round, or polygonal cells 
lying in close proximity. Cell-nests of varying size may be present, thus 
greatly resembling carcinoma. Melanosarcomas of the corneoscleral region 


DISEASES OF THE CONJUNCTIVA. 


245 


spring from nevi and often show a structure resembling that of ngevus 
pigmentosus of the conjunctiva and skin. These so-called “alveolar forms” 
led Panas to class all melanotic tumors of the corneoscleral region as 
carcinomas—a view which has been shown by Iverschbaumer to be incorrect. 

Early in its history a sarcoma causes no symptoms. After the growth 
has become larger there is pain and redness. The mass becomes anchored 
to the cornea and spreads over it. It may involve the whole conjunctiva 



Fig. 205.—Growth of conjunc¬ 
tival epithelioma into the cornea. 
(De Beck.) 



Fig. 200.-—Microscopic section of an epithe¬ 
lioma of the conjunctiva advancing into the 
cornea. (De Beck.) 


The epithelial growth is seen extending At the right is the normal corneal epithelium ; at the 

to either side of the limbus. The flat tumor, left this passes into the irregular cells of the new growth, 
resembling a condyloma, is attached to the 
limbus by a central core of connective tissue. 


without penetrating the globe; or it may gain access to the interior of the 
eye by burrowing between the scleral lamellae, or between the corneal 
layers, or by following the lymph-spaces of the anterior ciliary vessels. 
When the intra-ocular tissues are involved by an epibulbar sarcoma, in¬ 
creased tension is rarely observed. The melanotic form grows rapidly, 
often forming metastaseg. These black tumors are easily recognized. Epi¬ 
bulbar sarcomas occur chiefly in persons above fifty years of age. Three 
of the reported cases occurred in children. The author’s case (Fig. 204) 
was that of a middle-aged negro. 







246 


MODERN OPHTHALMOLOGY. 


Epibulbar leucosarcomas are often confounded with epitheliomas. The 
latter are flatter, are more cracked, and show a smaller lobulated structure; 
the sarcomas are elevated, and show a smooth surface or large lobules. 
The epitheliomas are solid, while the sarcomas are elastic. The former are 
likely to grow into the lid, while the latter are more apt to spread into the 
globe. However, it will often occur that the exact nature of a malignant 
tumor of the conjunctiva can be determined only by microscopic study. 
This is particularly true if the tumor is removed while yet small. Fortu¬ 
nately sarcoma of this region is rarely seen. Of 67 cases of sarcoma of 
the eye tabulated by Kerschbaumer, 9 were epibulbar; 5 of these were 
leucosarcomas, 2 were leucosarcomas with hematogenous pigmentation, and 
2 were melanosarcomas. A peculiar form of sarcoma known as cylindroma 
has been observed in the conjunctiva. 

It is possible to mistake an epibulbar sarcoma for tubercular granu¬ 
lation tumors, which pierce the corneoscleral region, or for an intra-ocular 
sarcoma piercing the sclera in front. The history of the case should suffice 
to prevent such a mistake. Danvers states that in some cases the differential 
diagnosis between the ocular form of spring catarrh and sarcoma of the con¬ 
junctiva can be made only by microscopic examination. 

Treatment. —Any suspicious tumor growing from the conjunctiva 
should be subjected to an early and thorough removal. A microscopic diag¬ 
nosis can then be made and the case can be carefully watched. If a sar¬ 
coma has involved the tissues of the globe, an enucleation will be neces¬ 
sary. The prognosis in these cases is favorable only if the operation be 
undertaken early. If the tumor involves the capsule as well as the globe, 
an exenteration of the orbit must be made. 

Epithelioma.—This disease, attacking by preference those parts of 
the body where one epithelium joins another, as the lips, nose, etc., begins 
in the conjunctiva near the corneoscleral junction (Fig. 8, Plate VII). 
Here there is not so much difference in the epithelial covering as in the 
character of the underlying tissues. An additional factor in the develop¬ 
ment of this type of tumor in this region is the peculiar arrangement of 
epithelium at this place, for in normal sections the epithelium is often found 
growing into the corneal tissue in the form of conic processes. 

The tumor begins as a small, rounded, or nodular, hard mass, slowly 
increasing in size and not painful. Eventually it spreads to all the ocular 
structures. Microscopically it is found that round-cell infiltration precedes 
the advancing growth of epithelial cylinders. The cylinders grow along the 
corneal canals. The corneal lamellae become broken up and destroyed, 
Bowman’s layer disappears, and the membrane of Descemet resists the 
longest. When it ruptures, the iris becomes fastened in the wound and the 
new growth spreads to the deeper structures. On the other hand, the 
epithelioma may spread along the lymph-sheaths of the anterior ciliary 
arteries. Often these tumors are lobulated and overlap the cornea, from 
which they can be lifted with a probe. The cornea may appear not to be 


DISEASES OF THE CONJUNCTIVA. 


247 


infiltrated, but only flattened by the mass, but microscopic section will 
show it to be involved. The surgeon, under these circumstances, shaves the 
growth off level with the cornea, touches the base with the electrocautery, 
and expects a cure. Almost invariably, however, there is a recurrence, but 
not necessarily at the old site. The microscopic appearances are repre¬ 
sented in Fig. 206, where the normal corneal structure is shown on the 
right and the advancing apex of the tumor is seen on the left. These 
tumors are rarely pigmented. They are found in middle-aged and elderly 
persons. Although springing usually from the limbus, epitheliomas some¬ 
times grow from other parts of the conjunctiva. 

Diagnosis may be difficult or impossible until after microscopic 
examination. 

Prognosis. —Epithelioma of the conjunctiva is always a serious dis¬ 
ease. If removed early and thoroughly it may not return. 



Fig. 207.- —Eye-clrop bottle (Chalk) and aseptic flask (Stroschein). 


Treatment. —When small, the cornea not being involved, the growth 
is to be excised. If large, or with considerable involvement of the cornea, 
the eye must be enucleated. Exceptionally cases occur in which removal 
of a tumor which involves the superficial layers of the cornea will not be 
followed by a recurrence. If the growth is large and has extended into 
the eyeball, it will be advisable to remove all of the orbital contents. 


INFLAMMATIONS OF THE CONJUNCTIVA. 

Inflammations of the conjunctiva are characterized by hyperemia; 
abnormal amount of secretion, which may vary from lacrimation to the 
production of mucus or pus; pain, which may be slight or severe; and 
dread of light (photophobia). The most noticeable of these changes, in 
case of a slight inflammation, is the increase in vascularity. It is necessary 
to distinguish the hyperemia of conjunctivitis from that which occurs in 
keratitis and deep-seated ocular diseases, such as iritis, chorioiditis, and 
iridochorioiditis. The former is known as conjunctival , and the latter 



















































248 


MODERN OPHTHALMOLOGY. 


as ciliary injection. Although in severe forms of inflammation of the 
anterior ocular segment the two types of congestion are associated, as would 
be expected from the numerous anastomoses between the posterior conjunc¬ 
tival and the anterior ciliary vessels, yet in many cases they can be readily 
distinguished. The points of differentiation between these forms of hyper¬ 
emia are as follows:— 


Conjunctival Injection (Fig. 208). 

1. Comes from the posterior conjunc¬ 

tival vessels. 

2. Is found in conjunctival diseases. 


Ciliary Injection (Fig. 209). 

1. Comes from the anterior ciliary 

vessels. 

2. Is found in diseases of the iris, 

ciliary body, and cornea. 



Fig. 208.—Congestion of the posterior conjunctival vessels. (Author.) 

(Original drawing by Du. R. W. Mills.) 


3. Is movable with the conjunctiva 

when pressure is made with the 
eyelid intervening. 

4. The greatest redness is posteriorly, 

in the fornices. 

5. Redness lessens toward the cornea. 

6. Color is a brick-red. 

7. Is composed of coarse, tortuous, su¬ 

perficial vessels whose meshes can 
be discerned. 


Hyperemia of the Conjunctiva 

(acute) or passive (chronic). 


3. Is immovable when the conjunctiva 

is moved. 

4. Greatest redness is circumcorneal. 

5. Redness lessens toward the fornix. 

6. Is of a pink or lilac color. 

7. Is composed of a series of fine, 

straight vessels radiating from the 
periphery of the cornea. The indi¬ 
vidual vessels are not easily recog¬ 
nized. 

(Dry Catarrh).—This may be active 




DISEASES OF THE CONJUNCTIVA. 


249 


Acute Hyperemia is the first change noticed in catarrhal or in 
purulent conjunctivitis. In this place, however, reference is had to idio¬ 
pathic hyperemia and to that form which may be due to the temporary 
lodgment of foreign bodies in the conjunctival cul-de-sac. The causes are 
numerous, and include the lodgment of cinders and particles of dust; the 
exposure to irritants, such as smoke, chemicals, strong winds, and bright 
light; the abuse of alcoholic beverages; and the strain of an uncorrected 
or improperly corrected error of the muscle-balance or of the refraction. 
Beginning presbyopia is a frequent cause. Hyperemia is often found in 
the early stage of cataract and in small corneal opacities. In some cases 



Fig. 209. —Ciliary injection. (Author.) 

(Original drawing by Dr. R. W. Mills.) 

of the gouty diathesis acute hyperemia, which may be recurrent, is found. 
Excessive and prolonged use of the eyes at near points, the presence of 
catarrhal or atrophic inflammation of the nasal mucous membrane, and 
disease of the accessory sinuses will cause vascular engorgement. 

Symptoms. — These include a sensation of irritation or discomfort 
about the eyes. They feel as if “sand” were in them. They are heavy and 
their use soon causes them to tire. In case of the lodgment of a foreign 
body the eye becomes rapidly red and there is profuse lacrimation. Pho¬ 
tophobia is a common symptom. Inspection shows congestion of the 
posterior conjunctival vessels. 

Treatment. —From what has been said it is evident that search should 
be made for foreign bodies, nasal disease, and errors of refraction. The 


250 


MODERN* OPHTHALMOLOGY. 


condition of the general health should be investigated. The correction of 
bad habits and removal from unhygienic surroundings will often be fol¬ 
lowed by immediate improvement. The local use of very hot water applied 
to the eyes for a few seconds thrice daily is beneficial. At night the 
patient can rub a small piece of the ointment of ammoniated mercury (1 
to 20) upon the closed lids. The use of a mild collyrium—boric acid, 
bicarbonate of soda, or camphor-water—is often advisable. A favorite 
mixture is: zinc sulphate, gr. 1 / 4 to 1 / 2 ; cocain, gr. j; water, §j, of which 
2 drops are to be used in the eye twice a day. The use of strong astringents 
is inadvisable. In applying a collyrium the surgeon everts the upper lid 
and drops the medicine upon it. If it is to be used at home, the patient 
should not attempt the eversion, but should pull the lower lid downward, 
at the same time looking down, while another person drops the medicine 
into the cup thus made. The lids can then be gently closed and kept closed 
for two or three minutes. The eye-dropper should always be held “right 
side up.” Inattention to this point will result in the medicine running 
into the rubber bulb, and thus foreign bodies may be dropped into the 
conjunctiva along with the medicine. In the application of collyria the 
surgeon should use one of the numerous antiseptic droppers and bottles, 
of which those of Galezowski, Chalk, and Stroschein are among the best. 

Passive Hyperemia. —In this form of congestion the venous circula¬ 
tion is interfered with, the veins being larger and more tortuous than under 
normal conditions. This often leads to hypertrophy of the papillae of the 
conjunctiva. Passive hyperemia is found after paralysis of the cervical 
portion of the sympathetic nerve. It is common in gouty persons and in 
those who are ametropic. The proper treatment consists in the removal 
of the cause and the use of mild astringent collyria. 

Conjunctivitis exists where the presence of an abnormal sedretion 
is added to hyperemia. Almost all forms of conjunctivitis are contagious. 
Although they produce certain pathologic changes in the affected membrane, 
it must be remarked that there is often no definite and constant result 
following the transmission of secretion from a diseased to a normal eye. 
The same secretion, obtained from an eye the seat of conjunctivitis, may be 
inoculated into several healthy eyes and produce a different clinical picture 
in each. Hence it is supposed that the type of inflammation set up is 
influenced by other than the bacterial cause. The role of the toxins in 
inflammatory processes offers an inviting field for study. So long as the 
protective epithelium of the conjunctiva and cornea is intact, the patient 
is comparatively safe from microbic invasion (Randolph). Doubtless every 
form of conjunctivitis, except the chemical or mechanical, is due to bac¬ 
teria, although it is yet too early to found a classification of the conjunc- 
tivitides solely upon bacteriologic causes. Hence, in the pages to follow the 
author will classify these affections from their clinical pictures, speaking 
of the concomitant bacilli and cocci as etiologic factors. According to the 
secretions present and the pathologic changes found, inflammations of the 


PLATE IX, 

Bacteria Found in Conjunctival Inflammations, (Schanz.) 


Fig, 1. 

Streptococci, 


Fig, 2, 

Diphtheria Bacilli. 


Fig. 3. 
G-caocooci. 


Fig, 4, 

Diplctiacilli of 
Morax-i5xanfeld. 


Fig. a. 

Kcch-Weeks Bacilli. 


Fig, B. 

Pnaumococci, 
















■XT aTAJ*! 


(.SMH32) ■5,iif2?»flSr.. n of 

i jv ■ 'i uuh ygienii urroundir ..s will often be fol- 
■0 ‘mend i he. ;-:■ 1 use of v >•' hot water applied 
)iids 1 1 • r:■ d<; ■ brn< v ial. At night the, 

piece of the da-m X of armnoihafced mercury (1 
I P'ds. The ft! O' 1' mild' -odyrium.—boric acid, 
,, ot eair:phor-w.He.v—•3 viteu a ivifabie. A favorite 

• ate g] \ ■ ► ■ e m l. gr. j: water, X. A hi<& 

S' r vji 1 ^ 

.nOofiH .■sirarfirfq^a ■' tuactiatqp-tik ~ ' 

•, toplving a go By r hr: n ‘he surgeon everts the upper lid 
;!• • upon it. If it is to be vised at home, the 'patierr 
; • ■ eversion, but should pail the lower lid downward, 

.n;;- down, while jinuther person drops the medicine 
The lid* can hen be genby closed, and kept closed 
■ ri>•= The v> ro| >or should always be held : righ t 
(/, > 1 , xo il’s . . X: result in the medicine running 
, b bed-os may be dropped into the 

; . 1 io.i ■; cob ia he 
■ tv 'droppers and bottles, 
j >t« among tbe best. 
‘i£<? venous circuli- 
,<ous than under 




•» -*K 

la ILUajacfalq'.'.fT 


ot.. u-n 

.e .’jjpr 

jtnoeatijjoa 


of vbe 


\( a i 

■ d in 








•( .■:xt?t tv 1 pus are contagion-: 

. ngv- m the wA-eted mem or. u*. 

' m du* and c n 1 :v . '.suit ' 

>n j. a diseased' to a normal eye. 

... *>:•• o-yv, the seat of cenjuiictivil p may be 
.'■• ;• >•••- p’o produce a different clinical picture 
■ type of inflammation set up ifc 
cause. Tbe role of tbe toxins in' 
lb del for study. 80 long as the 

,b ■ "-' i rri ie .giT ’ brer, the patient 

.iaaouajjMiBJj'T W-dabTC:: .rh-,s CYH'y 

i or tneeham-,il. is due to bae- 
■ ; d - la.--h.eai. or o ' the conjune- 
. r lienee, iu the page - to follow the 
p ,1 ■ r from their clinical pictures, speaking 

ctiologic facto w. Ac orchng to the 
- cl'cnges found, inflammati *<m of the 





PLATE 9 








DISEASES OF THE CONJUNCTIVA. 


251 


conjunctiva are classified as catarrhal, purulent, diphtheritic, granular, and 
phlyctenular. As a rule, the prognosis of inflammation of the conjunctiva 
is favorable. Many cases, however, of the purulent and granular forms 
lead to corneal complications; and occasionally an eye is lost either from 
the neglect of the patient to consult a skilled surgeon at an early date, from 
injurious methods of treatment, or from the violence of the inflammation. 

Simple Conjunctivitis (Catarrhal Conjunctivitis; Catarrhal Ophthal¬ 
mia).—This is a mild form of conjunctivitis (Fig. 5, Plate VIII) which is 
accompanied by swelling of the membrane and lids and a muco-purulent 
secretion. The disease tends to spontaneous recovery. It begins with a 
burning or smarting sensation, which is more pronounced before the appear¬ 
ance of secretion. The conjunctiva, particularly in the region of the for- 
nices, is hyperemic. In severe cases the conjunctiva is swollen; there is 
photophobia and increased lacrimation. Often the movements of the eye 
and accommodative effort will cause pain. One or both eyes may be in¬ 
volved. Vision is affected only when mucus adheres to the cornea. 

Etiology. —The mechanical and traumatic varieties of simple con¬ 
junctivitis result from the presence in the cul-de-sac of small foreign bodies 
such as dust, pollen, insects, etc. The disease is associated often with the 
exanthemata, such as small-pox, measles, scarlatina, influenza, eczema, 
blepharitis marginalis, and facial erysipelas. It is a common accompani¬ 
ment of acute coryza. Scrofulous subjects and persons having folliculosis 
are particularly susceptible to this disease. Streptococci, staphylococci, and 
pneumococci are present in severe cases. According to Gifford, the pneu¬ 
mococcus of Fraenkel is a common cause of simple conjunctivitis. On the 
other hand, Morax and Parinaud regard this bacterium as an infrequent 
cause of this form of conjunctival inflammation. 

The pneumococcus of Fraenkel (known also as the diplococcus pneu¬ 
moniae of Weichselbaum, micrococcus lanceolatus of Talamon, and micro¬ 
coccus Pasteuri of Sternberg) is in the form of oval cocci, often arranged 
in pairs or chains, with the free ends often pointed and encapsulated (Fig. 
6 , Plate IX). 

Diagnosis and Prognosis. —From the foregoing description it will 
be noted that the diagnosis is generally an easy matter. If in doubt, a 
microscopic examination will be conclusive. The prognosis is favorable. 

Treatment. —When the cause is removed these cases tend to sponta¬ 
neous recovery. Cleanliness is an important factor in treatment. The 
eyes should be washed with hot water two or three times daily. A 1-per¬ 
cent. strength solution of boric acid, a 1 / 5 -of-l-per-cent. solution of chlorid 
of zinc, a 1 to 15,000 solution of bichlorid of mercury, or the zinc-cocain 
solution previously mentioned may be used twice daily with benefit. Pro- 
targol (5 to 10 per cent.), largin (5 to 10 per cent.), argentamin (2 to 5 
per cent.), and argyrol (5 to 10 per cent.) are valuable remedies. Smoked 
glasses should be prescribed. Poultices of any kind are absolutely contra¬ 
indicated in all forms of conjunctivitis. After recovery, the condition of 


252 


MODERN OPHTHALMOLOGY. 


the refraction should be investigated and ametropia, if found, should be 
corrected. 

Acute Contagious Conjunctivitis (Acute Catarrhal Conjunctivitis; 
“Pink Eye”; Epidemic Ophthalmia; Acute Muco-purulent Conjunctivitis). 

—This is an acute inflammation of the conjunctiva, having a definite period 
of incubation. It is accompanied by a muco-purulent discharge, and both 
eyes are usually affected. The disease is more common in. the spring than 
in the fall months and often becomes epidemic. It is not limited to any 
country or climate. It is found at all ages except possibly during the first 
ten days of life. 

Etiology.— Since Koch studied this disease in Egypt in 1883, finding 
a bacillus resembling that of mouse-septicemia; and Weeks in 1886 was 
able to make pure cultures of this bacillus and produce the disease in healthy 
conjunctivas; and Morax, Hansell, and others confirmed these observations, 
great stress has been laid upon the Koch-Weeks bacillus as the cause. This 
bacillus (Fig. 5, Plate IX) stains readily with anilin dyes and often is 
associated with the xerosis bacillus. In the last few years, however, it has 
been shown that the pneumococcus is more often the cause of acute catar¬ 
rhal conjunctivitis than is the bacillus just described. Gasparini in 1893 
was the first investigator to note that the muco-purulent type of conjunc¬ 
tivitis could be caused by the pneumococcus. The investigations of Gifford, 
who found the pneumococcus in 36 of 40 cases, and of Junius, who met 
with it in 49 of 60 cases of acute catarrhal conjunctivitis, have gone far 
toward the settlement of the etiology of this disease. Gifford carried the 
disease to healthy eyes by means of the discharge, and always found the 
pneumococcus in the discharge from the inoculated eye. In 31 of the 60 
examinations made by Junius the pneumococcus was found in a pure state; 
in 18 it was associated with the staphylococcus or with the xerosis bacillus. 
Eecent investigations by Yeasey show that for Philadelphia and vicinity 
the most frequent cause of acute catarrhal conjunctivitis is the pneumo¬ 
coccus of Fraenkel. Of 64 cases examined by this observer, the pneumo¬ 
coccus was present in 52. In 10 of these the pneumococcus was mixed with 
other bacteria. Those cases in which the micrococcus pyogenes albus or 
aureus was present were mild in character. In only three of Veasey’s cases 
was the Koch-Weeks bacillus present. Occasionally the disease is produced 
by the Koch-Weeks bacillus. The clinical signs of both infections are so 
similar that in severe cases only a bacteriologic examination can distin¬ 
guish between them. 

Atmospheric influences are supposed etiologic factors, the disease being 
more common at those seasons of the year when coryza, influenza, and 
exanthemata prevail. The infection is often carried by washing utensils, 
such as towels and handkerchiefs, particularly in barracks, work-houses, 
orphan asylums, and hospitals. 

Pathology.— There is great enlargement of the conjunctival vessels, 
apparent increase in the number of small vessels, thickening of the con- 


DISEASES OF THE CONJUNCTIVA. 


253 


junetiva, particularly in the fornices, from vascular engorgement and serous 
effusion, and slight infiltration of leucocytes at the base of the epithelial 
layer of the conjunctiva and between the cells. Pneumococci or bacilli are 
present in the discharge. 

Symptoms. —About thirty-six hours after infection the eyelids smart, 
and later the lashes are glued together with the drying of the discharge. 
The conjunctiva is hyperemic and the eye looks red and swollen. The 
discharge increases. At first it is chiefly mucus (normal secretion and 
shed epithelium), of which small, stringy masses float in the lacrimal 
secretion, and is of a gray or whitish color. When the proportion of pus 
increases, the discharge is yellowish, and may be so profuse as to simulate 
gonorrheal infection. In a few cases a pseudomembrane appears, and, in 
the absence of a bacteriologic examination, such cases may be mistaken 
for diphtheritic conjunctivitis. The eye is of a bright-red color; hence the 
name “pink eye.” The patient often complains of the sensation of a 
foreign body, and in delicate nervous subjects pain may be a prominent 
symptom. Vision is blurred from the smearing of the discharge over the 
cornea. Use of the eyes causes pain. The disease usually reaches its height 
on the third or fourth day. The bulbar conjunctiva may be slightly or 
greatly involved, according to the severity of the process. When it is much 
swollen, with a large serous exudation lifting it up around the cornea, the 
condition is named chemosis. This may be so great as to cause the swollen 
tissue to protrude between the eyelids. In some severe cases small hemor¬ 
rhages appear in the conjunctiva. The acute stage of catarrhal conjunc¬ 
tivitis lasts from five to ten days, the disease tending, in the majority of 
cases, to spontaneous recovery. If neglected, it may remain a long time 
in the subacute or chronic form. Corneal complications are rare. The 
development of corneal disease, characterized by an increase in pain and 
photophobia, begins at or near the limbus in the form of small, opaque, 
gray spots often arranged concentric with the corneal periphery. In a 
few days these points unite to form a concentric infiltration. Later the 
epithelium breaks down, and thus an ulcer is produced, which is known 
as a catarrhal ulcer. Generally it heals rapidly, leaving a minute scar, 
which from its location cannot interfere with vision. In rare instances 
such an ulcer leads to general corneal infection and perforation. Such a 
disastrous result is exceedingly rare in cases properly treated, but may 
follow improper treatment: e.g., the use of poultices. In almost all cases 
both eyes are affected in acute conjunctivitis. In one the inflammation 
may be at its height, while in the other it is beginning. 

Diagnosis. —The bacteriologic diagnosis depends on the finding of 
the pneumococcus or the Koch-Weeks bacillus. The student or practitioner 
who is familiar with laboratory methods will have no difficulty in this 
respect. For the majority of practitioners, however, the clinical diagnosis 
will suffice. The presence of a discharge, the location of the greatest redness 
in the region of the fornices, and the character of the secretion, in the vast 


254 


MODERN OPHTHALMOLOGY. 


majority of cases, will enable the practitioner to make the diagnosis without 
difficulty. It is only in the rare cases where the presence of a pseudo¬ 
membrane simulates diphtheritic or where a profuse purulent discharge 
resembles gonorrheal ophthalmia that doubt may arise. In such instances 
the history of the case and attention to the symptoms of these affections as 
described elsewhere in this chapter, will serve to clear the diagnosis. If any 
doubt remains, a bacteriologic examination should be made. It must be 
remembered that iritis may exist and be overlooked during an attack of acute 
catarrhal conjunctivitis (see “Iritis”). A more common mistake is to call 
iritis catarrhal conjunctivitis. 

Clinical Yaeieties. —Attention must be called to certain forms of 
catarrhal inflammation which are of sufficient importance to deserve men¬ 
tion. Thus, traumatic conjunctivitis results from blows, the lodgment of 
foreign bodies, the action of chemicals, the irritating effect of dust (found 
among millers, masons, etc.), the effect of exposure to bright light (electric 
welding, snow-blindness), repeated exposures to the x-rays, and to inocula¬ 
tion of animal matter found around slaughter-houses. In such cases pho¬ 
tophobia, lacrimation, pain, and swelling are likely to be symptoms of 
unusual prominence, and edema of the lids and superficial corneal ulcera¬ 
tion are common. A severe form of the disease is observed in gas-fitters. 

Exanthematous conjunctivitis is found in connection with eruptive 
diseases, particularly rubeola. Follicular conjunctivitis , which is classed 
by some authors with catarrhal and by others with trachomatous inflamma¬ 
tions, will be considered separately. In the form of conjunctivitis known 
as vesicular catarrh the tarsal conjunctiva is covered with numerous small 
elevations, which Arlt compared to the appearance of fine sand scattered 
over a moist glass plate. A rare form is the 'pustular conjunctivitis , in 
which pustules appear on the bulbar conjunctiva and leave small grayish 
or yellowish ulcers. This disease resembles phlyctenular conjunctivitis. 
In the latter affection the conjunctiva of the fornices and lids is only 
slightly or not at all affected, while in pustular conjunctivitis they show 
signs of catarrhal inflammation. Pink eye is a form of epidemic catarrhal 
conjunctivitis affecting the lower animals as well as man, and is trans¬ 
mitted by the atmosphere. A mild form of catarrhal inflammation, bi¬ 
lateral, and found in gonorrheal or gleety subjects who have joint compli¬ 
cations, has been named metastatic gonorrheal conjunctivitis. 

Prognosis. —Acute catarrhal conjunctivitis tends to recovery. It is 
only in cases of unusual severity, and in those in which poultices or other 
improper methods of treatment are used, that serious complications ensue. 
Ordinarily, under the use of cleanliness and astringents, the disease yields 
readily, and the patient can be discharged in from ten to fourteen days. 

Treatment. —Bemoval to proper surroundings where the air is pure 
and free from dust is advisable. Cleanliness is of importance. The eyes 
should be bathed often in hot water. The chief remedy for catarrhal con¬ 
junctivitis is a solution of nitrate of silver applied to the everted lids once 


DISEASES OF THE CONJUNCTIVA. 


255 


a day. The strength of the solution should vary according to the intensity 
of the inflammatory process. Ordinarily a solution of the strength of gr. 
ij to will be sufficient, but for severe cases gr. v will be better. A 
stronger solution than this is never needed in the treatment of this disease. 
In using a solution of the strength mentioned it will be unnecessary to 
neutralize the excess of silver with a solution of chlorid of sodium.' Be¬ 
tween the daily treatments by silver the following collyrium, which is 
highly recommended by J. H. Thompson, of Kansas City, can be used: 
Boric acid, oiss; calcined magnesia, 0ss; water, giij. Mix and filter. A 
few drops of this can be used in the eye every four hours. When chemosis 
and edema are marked symptoms the application of cold compresses for a 
few minutes will be useful. In such cases some ophthalmic surgeons favor 
the direct application of ice to the closed lids. From its blanching prop¬ 
erties it might be supposed that a 2- to 5-per-cent, solution of the extract 
of suprarenal capsule would be useful when dropped into an inflamed 
conjunctiva, but its effect is only temporary, and the inflammation returns 
with force equal to or greater than before. Adrenalin chlorid (1 to 10,000) 
may be used with benefit. It is a powerful astringent. 

Protargol has lately come into extensive use in conjunctival inflam¬ 
mations. It possesses no advantages over silver except that its application 
is attended by less pain. It is used in 5-, 10-, and 20-per-cent, strength 
solutions. Largin in 10-per-cent, solution is highly recommended by Sydney 
Stephenson as a substitute for nitrate of silver. Argyrol (5 to 20 per cent.) 
is a valuable remedy. Sulphate of zinc (gr. j to §j) is a valuable astrin¬ 
gent, and can be used three times a day. Acetate of lead in the same 
strength is an excellent remedy, but in many cases it cannot be used, for the 
reason that, wherever the corneal epithelium has been removed this agent 
will form an indelible white deposit of lead carbonate, and thus will impair 
vision. An excellent prescription for acute catarrhal conjunctivitis is this: 
sulphate of hydrastin, gr. v; boric acid, gr. ij; biborate of soda, gr. iv; 
deodorized tincture of opium, oss; water, to make §j. Of this a few drops 
are used three times a day. Cuprol in 10-per-cent, strength solution, applied 
once daily, has been recommended. To preserve the efficiency of the drug 
a small amount of chloretone (0.5 per cent.) should be added. The author's 
experience with cuprol has been unsatisfactory. In prescribing collyria dis¬ 
tilled water is often ordered when filtered water is better, since distilled 
water acts injuriously on epithelial cells (Thompson). Morphin is a 
remedy which is often prescribed for catarrhal conjunctivitis under the 
mistaken idea that it is soothing to an inflamed surface. It should not 
be used. If the pain "is severe it is better to use a few drops of cocain, or, 
if pain is due to corneal infiltration, atropin. Cocain, however, should be 
used only at long intervals, since it first contracts and then paralyzes the 
blood-vessels. A better agent is holocain, V 2 -per-cent. strength solution, 
which does not injure the vessels and has some antiseptic value. As a rule, 
the momentary application of very hot water will relieve the pain of con- 


256 


MODERN OPHTHALMOLOGY. 


junctivitis. The presence of corneal ulcers in catarrhal conjunctivitis does 
not constitute a contra-indication to the use of silver, but the surgeon 
should take care that the medicine shall not come in contact with the cornea. 
If chemosis is great the swollen conjunctiva should be anesthetized and 
numerous punctures should be made in it with a cataract-knife. Bandaging 
of the eyes and the application of poultices are absolutely harmful in this 
disease. The patient should be given a pair of smoked glasses, and should 
get out of doors. The use of tobacco (smoking) and alcohol should be for¬ 
bidden while he is under treatment. 

Subacute Catarrhal Conjunctivitis (Subacute Conjunctivitis of Morax- 
Axenfeld) is found in all ages, but is particularly frequent in old age. 
The onset is sudden. There is a slight muc-o-purulent discharge, and a sen¬ 
sation of smarting without pain. The disease is usually bilateral, and does 
not lead to corneal complications. It can be distinguished from mild and 
prolonged cases of acute contagious conjunctivitis by the bacteriologic find¬ 
ings. In the former disease the pneumococcus of Fraenkel or the Koch- 
Weeks bacillus is present, while the latter is attributed to a particular 
microorganism which has been studied by Morax, Axenfeld, and Gifford. 
It is a diplobacillus, two or three micromillimetres long and one-half as 
thick, appearing as two short rods separated by a clear space, and can be 
distinguished from the pneumococcus by having no capsule and appearing 
more rod-like (Fig. 4, Plate IX). Gifford, however, believes it to be encap¬ 
sulated. Morax found that a pure culture of it, carried through the fifth 
generation after incubation, causes typical inflammation in the human con¬ 
junctiva, but is not pathogenic for animals. It stains with dilute carbol- 
fuchsin and is decolorized by Gram’s method. Eyes infected with this germ 
give considerable variety in the clinical pictures presented, although in most 
cases the symptoms are subacute or chronic. The daily use of a 1 / 5 -per- 
cent. solution of chlorid of zinc readily cures the disease. 

Chronic Catarrhal Conjunctivitis. —This is a common disease which 
presents chiefly subjective symptoms. Objectively there is a moderate 
amount of hyperemia in the region of the fornices, or on the tarsus, or in 
both places. In many cases the conjunctiva is not swollen, while in those 
of long standing it looks velvety and is somewhat thickened. There is 
present a small amount of secretion, which is noticed chiefly by a matting 
together of the eyelashes in the morning, or by the presence of a dark crust 
at the inner angle of the eye. When this dried secretion is removed a thread 
of viscid mucus comes with it. The subjective symptoms include a feeling 
of heaviness or a sensation of sand in the eye, which symptom is more 
pronounced toward night; a burning or itching of the eyes, which tire 
quickly on accommodative effort; blurring of the sight, or the appearance 
of a rainbow around a light, caused by the spreading of mucus over the 
cornea; and often an annoying blinking and sensation of dryness. The 
disease is common among adults and elderly people and is likely to be of 
long duration. Frequently blepharitis marginalis is present. The skin 


DISEASES OF THE CONJUNCTIVA. 


257 


of the-lids becomes eczematous, and ectropion is common. This increases 
the flow of tears, and the effort of the patient to wipe these away with 
his handkerchief adds to the local irritation. Corneal ulcers often occur 
in these cases. 

Etiology. —The causes of chronic catarrhal conjunctivitis are nu¬ 
merous and include such dissimilar elements as failure to recover from 
an attack of acute inflammation, unhygienic surroundings, the injurious 
influence of certain vocations, abuse of alcohol and tobacco, exposure to 
wind and dust, eyestrain from an uncorrected error of refraction, the pres¬ 
ence of blennorrhea of the lacrimal sac, and the existence of nasal disease. 

Treatment. —If possible, the surgeon should first remove the cause. 
Under hygienic surroundings and mild treatment these cases show a rapid 
improvement. The eyes should be bathed frequently in hot water. The 
most popular remedies at present are argyrol, protargol, and nitrate of 
silver. The first and second are used in 5- or 10-per-cent, strength solu¬ 
tions, the third in the strength of 1 / 2 to 2 grains to the ounce. Mild cases 
improve rapidly under the use of the zinc-cocain solution, or a 1-per-cent, 
strength solution of boric acid. The use of the ointment of ammoniated 
mercury, rubbed on the lid-margins at night, is beneficial. The collyrium 
should be applied to the everted conjunctiva by a dropper or by a mop. 
After the lids show signs of improvement the refraction should be exam¬ 
ined. Often it will be found that hypermetropia or astigmatism is present 
in amount sufficient to explain the symptoms. 

Follicular Conjunctivitis (Folliculosis; Follicular Trachoma, or Ca¬ 
tarrh, or Ophthalmia.; Simple Granular Conjunctivitis).— In children 
chronic catarrhal inflammation of the conjunctiva appears generally in 
the form of folliculosis (Eig. 4, Plate VIII). The disease has been so 
named because of the enlargement of the adenoid tissue, which takes the 
form of small, round, or oval translucent bodies, which are seldom larger 
than a rapeseed and resemble follicles. They lift up the conjunctiva, form¬ 
ing small elevations, and are more numerous in the lower than in the upper 
fornix. Often they are arranged in rows parallel with the folds of the 
membrane. Under a magnifying glass they look like little spots of jelly. 
They ultimately disappear under treatment, leaving the conjunctiva intact. 
In this respect they differ from trachoma. They are sometimes found in 
acute catarrhal conjunctivitis. This form of conjunctivitis is to be regarded 
as an expression of a tendency toward adenoid enlargement. The con¬ 
dition is extremely common. Thus, of 14,797 children, whose ages ranged 
from 2 to 19 years, Sydney Stephenson found only 5.55 per cent, with 
normal conjunctiva}; 93.99 per cent, presented folliculosis, and 0.46 per 
cent, had trachoma. 

The question of the relationship between folliculosis and trachoma has 
caused much controversy. It is now generally accepted by ophthalmic sur¬ 
geons that they are clinically distinct diseases, although histologically there 
is no line of demarcation between fresh follicles and fresh trachoma bodies. 


17 


258 


MODERN OPHTHALMOLOGY. 


In the absence of discharge from the eye follicnlosis is not contagious. It 
tends to a spontaneous recovery without scarring of the conjunctiva. It 
is not associated with corneal complications, or with structural changes 
in the tarsal plate, and it never causes trichiasis, entropion, or ectropion. 
Trachoma, on the other hand, is always conditionally contagious, and is 
often associated with pannus, corneal ulceration, trichiasis, entropion, or 


ectropion. Folliculosis is rare after the 
be seen at any age. 

The appearance of the conjunctive 
as follows (Stephenson) :— 

False, or Follicular, Granulation. 

Oval or roundish, transparent bodies, 
the diameter of which seldom or never 
exceeds 1 or 1.5 millimetres. They 
often show a faint-yellowish hue, and 
are usually arranged in rows. Their 
tendency is to remain discrete: that 
is, separate from one another. They 
are always larger and better marked 
in the lower fornix. 


twentieth year, while trachoma may 
in each affection may be described 

True, or “Sago-grain,” Granulation. 

Round, opaque, ill-defined bodies, of 
grayish-white color, and extreme fria¬ 
bility. They are firmly and deeply 
imbedded in the conjunctiva, their di¬ 
ameter frequently reaching 2 milli¬ 
metres or more. Their tendency is to 
become confluent, thus forming areas of 
trachomatous material. They are al¬ 
ways larger and more numerous in the 
upper fornix. 


Etiology and Pathology. —Follicular conjunctivitis is often said 
to be caused by unhygienic surroundings, but Stephenson has shown that 
practically no difference exists in the percentage of cases of folliculosis 
among the inmates of schools of good, medium, and poor social status. 
Folliculosis is often found among the children of farmers, among whom 
there is no lack of fresh air and sunlight. Among children, sex and age 
are without etiologic meaning. The disease, however, is often found in 
individuals who have enlarged cervical, femoral, or axillary glands, h} r per- 
trophy of the tonsils, adenoid growths in the pharynx, granular pharyn¬ 
gitis, and swollen gums. The conclusion seems evident that folliculosis is 
to be regarded as an expression of adenoid activity incident to childhood 
and } T outh. Some authors hold that the disease is contagious; others, that 
it is caused by vitiated air. The prolonged use of eserin will cause it 
(Juler). It is also seen after the use of atropin, particularly after the 
use of impure solutions. Some observers hold that dry atropin will cause 
it. It is probably due to a germ, hut this opinion is only a supposition. 

Pathology. —Microscopic section of the enlarged follicles shows them 
to be composed of a mass of lymphoid cells, held by a network of connective 
tissue, forming an incomplete capsule. 

Prognosis. —The prognosis of folliculosis is favorable as regards 
vision, and so far as ultimate return to the normal condition of the con¬ 
junctiva is concerned; hut the disease often is rebellious to treatment. In 
the course of years the follicles may disappear without treatment. 

Treatment. —In considering the treatment of this disease it is ad¬ 
visable to distinguish between (1) cases without and (2) those with 



DISEASES OF THE CONJUNCTIVA. 


259 


catarrhal symptoms. In the first class the conjunctiva often is pale, but 
may show arborescent vessels. It presents the oval vesiculo-grains which 
have been described, and there is no discharge from the eye (folliculosis of 
Adamiuk). Aside from attention to the general health these patients need 
no treatment. If the follicles are unusually abundant, the daily use 
of a 1 / 2 -per-cent. strength solution of silver nitrate, or a 10-per-cent, solu¬ 
tion of argyrol, is advisable; or the surgeon can express the contents 
of the follicles with the roller forceps, a procedure which greatly shortens 
the period of treatment. 

The second class presents a mucous or muco-purulent discharge, which 
is rarely abundant, but is in sufficient amount to cause the eyelashes to be 
glued together. The conjunctiva shows the vesiculo-grains. It is some¬ 
what reddened and slightly thickened (follicular conjunctivitis). This 
form demands treatment. Here nitrate of silver or argyrol is indicated. 
Stephenson has obtained good results from the use of a carefully prepared 
ointment of the subacetate of lead (1 per cent.), of which a small piece is 
applied to the everted conjunctiva once a.day, followed by massage. After 
two weeks' time the strength of the ointment is to be doubled. Under this 
treatment the redness disappears, the discharge ceases, and the follicles 
become reduced in size and finally disappear. The use of bluestone and 
strong solutions of silver is not advisable in this disease. Follicles which 
refuse to yield can be subjected to expression, or each follicle can be touched 
with the fine point of the galvanocautery. This method of treatment re¬ 
quires a tractable subject and great patience on the part of the surgeon. 
After the disappearance of the disease it will be well to search for errors 
of refraction. 

Drug Conjunctivitis (Atropin Conjunctivitis) is the name which may 
properly be applied to those uncommon cases of conjunctival follicles which 
are caused by the application of certain medicines (atropin, cocain, homat- 
ropin, hyoscyamin, duboisin, eserin, and arecolin) to the conjunctiva. The 
toxic effect may follow a single application of the drug or may come only 
after prolonged use of it. In the former case the skin of the lid becomes 
dry, red, and swollen and may appear like erysipelas. Examination will 
show the presence of follicles, which are particularly numerous in the lower 
fornix. This type of the disease is more often found in adults than in 
children. 

In the second form, after long use of a mydriatic or miotic, there 
is the sudden appearance of an acute catarrhal conjunctivitis with muco¬ 
purulent discharge. Inspection shows the presence of follicles. 

Etiology. —Glorieux considers that the affection is a paralysis of the 
vasomotor nerves, with sequent dilation of conjunctival vessels. Idiosyn¬ 
crasy must be a factor in some cases. A frequent cause is the presence of 
germs in the solution used or the existence of a chemical impurity. Some 
cases are caused by the transference of septic material by unclean eye¬ 
droppers. 


260 


MODERN OPHTHALMOLOGY. 


Treatment. —The use of the drug should be discontinued and hot ap¬ 
plications of the dilute subacetate of lead can be used. De Schweinitz uses 
a 1-per-cent, strength solution of creolin in atropin conjunctivitis. Tannin 
and glycerin solutions are valuable remedies. The skin of the lids should 
be smeared with the ointment of ammoniated mercury (1 to 20). 

Vernal Conjunctivitis (Spring Conjunctivitis; Fruejahr's Catarrh; 
Phlyctenula Pallida; Circumcorneal Hypertrophy of the Conjunctiva).— 
This is a rare form of chronic catarrhal inflammation (Fig. 6, Plate VIII) 
which is characterized by hypertrophy of the conjunctival epithelium, the 
presence of an exudation into the corneoscleral margin, and the presence 
of peripheral opacities of the cornea. The disease was first described by 
Arlt, in 1846. 

Symptoms. —The patient complains of the usual symptoms of con¬ 
junctivitis. Burning or itching sensations and heaviness of the lids are 
frequent symptoms. Sometimes photophobia exists. Inspection shows the 
presence of a slight mucous discharge and the existence of lacrimation, 
hyperemia, and hypertrophy. The conjunctiva presents a bluish-white 
color resembling a film of milk spread over the membrane. It is thickened, 
the papilla are prominent, and the hypertrophy causes large, fiat-topped 
elevations of a reddish-gray color. They are found in the upper lid and 
around the cornea. In England and France the tarsal type is prevalent, 
while in Italy and other Mediterranean countries the bulbar form is more 
often observed. The limbus may show a jelly-like band around the cornea; 
or minute red dots may be present in the space corresponding to the palpe¬ 
bral fissure. In some cases only that j^art of the bulbar conjunctiva is in¬ 
volved which corresponds to the opening between the lids. In some patients 
the hypertrophies are few in number, resembling mushrooms, while in others 
they are abundant. The lesions may exist chiefly in the tarsal region or 
in the palpebral area. The patient has a dull, sleepy look, owing to the 
slight ptosis which is present. A clinical feature is the fact that the dis¬ 
ease generally begins with the advent of warm weather in the springtime 
and continues during the summer and fall. It then disappears to return the 
following spring. Occasionally it persists during all the seasons. 

Etiology. —The disease is almost limited to children between the ages 
of five and fifteen years, but when once set up the process may continue 
indefinitely. Both eyes are generally affected. Its etiology is unknown. 
Malaria and uterine disorders are supposed to be etiologic factors. The dis¬ 
ease is of frequent occurrence in southern countries, but latitude alone is 
not a determining factor. Vernal conjunctivitis appears during the spring 
and summer months. It occurs in all grades of society and is not influenced 
by occupation or by exposure to the rays of the sun. The disease is sporadic 
and non-contagious. 

Diagnosis.— Spring conjunctivitis is to be differentiated from tra¬ 
choma and from phlyctenular conjunctivitis. Spring conjunctivitis should 
not be confounded with the conjunctivitis attending hay fever. The 


DISEASES OF THE CONJUNCTIVA. 


261 


latter type of cases presents more of the anatomic and few of the symp¬ 
tomatic points found in vernal conjunctivitis. The pericorneal elevations 
of vernal conjunctivitis are permanent or of long duration, and they do 
not break down and leave ulcers. These characteristics will prevent the 
confounding of this disease with phlyctenular conjunctivitis. The dif¬ 
ferentiation from trachoma can be made by attention to the following 
table, which is by Danvers:—• 

Vernal Conjunctivitis. 

Occurs in all grades of society. 

Granulations are situated on surface of 
tarsus, and consist of fleshy, flat 
growths, with pedicles and well- 
marked grooves between them. 

Growths never ulcerate on bulb or tar¬ 
sus. 

Pannus or corneal ulcer a rare excep¬ 
tion. 

Conjunctiva of tarsus has a bluish-white 
tinge. 

Disease heals without leaving any 
traces on cornea, tarsus, or fornix. 

In treatment, copper sulphate, nitrate 
of silver, and mercurial preparations 
always irritate the growths, and do 
no good whatever—in fact, are posi¬ 
tively harmful. 

Frequently the bulbar type of vernal conjunctivitis, with a single 
tumor-mass, can be differentiated from sarcoma and epithelioma only by a 
microscopic examination. 

Pathology. —Microscopic sections of parts of the affected area show a 
proliferation of epithelial cells and the presence of lymphoid cells with 
bands of connective tissue in the large granular bodies found on the con¬ 
junctiva. 

Prognosis. —The prognosis is favorable in the sense that the disease 
does not cause serious lesions of the cornea. It is a disease of long duration 
and may recur every summer for many years. The bulbar variety offers a 
more favorable prognosis than the tarsal type. 

Treatment. —Many remedies have been proposed, but the most that 
can be done will be to relieve the distressing symptoms and stop the en¬ 
croachment of the disease upon the cornea. A complete recovery often 
follows after several years. The eyes can be bathed in hot boric-acid solu¬ 
tion, and ointment of yellow oxid of mercury or the ointment of ammoniated 
mercury can be rubbed into the conjunctiva once or twice a day. Bichlorid 
of mercury, zinc, silver, and other similar preparations can be tried in the 


Trachoma. 

Is essentially the heritage of the poor. 

Granulations seem to be deep in sub¬ 
stance of tarsus; oval in shape; of a 
grayish, transparent tint; and are 
seated more especially in the fornix, 
which they cause to atrophy. 

Ulceration rare. 

Gives a special form of pannus begin¬ 
ning on upper part of eomea; corneal 
ulcer frequent. 

Conjunctiva never bluish white, but a 
bright or dark red. 

Cicatricial tissue on tarsus and fornix 
always left; after pannus there may 
be fixed opacity of the cornea. 

All these substances are beneficial in the 
treatment of this disease. 



MODERN OPHTHALMOLOGY. 


op.o 

vU/V 

form of solutions. Van Milligen, who saw much of this disease in Con¬ 
stantinople, advises the use of a solution of acetic acid (from 1 to 20 
grains to the ounce), but this remedy is not ivell borne. Magnani, of 
Turin, and Gallenga, of Parma, use ice-cold packs, which are applied to 
the eyes for ten minutes at a time five or six times a day. Danvers lays 
stress upon the examination of the nose and pharynx as preliminary to the 
ocular treatment. Darier states that in vernal conjunctivitis silver and 
copper are valuable only when there is an abundant, stringy, muco-purulent 
discharge, and that the pericorneal form of the disease is to be treated by 
massage with mercurial ointment made with lanolin. Natanson and Bock 
report cases in which powdered xeroform was used with excellent results. 
Randolph uses salicylic acid in solution (1 per cent.) and as an ointment. 
If there is much pericorneal injection atropin and smoked glasses are to 



Fig. 210.—Section of growth in the bulbar type of vernal conjunctivitis. 

(Danvers.) X 100. 

The epithelial covering is proliferated and sends long, thin processes into the connective stroma. . 

In transverse section the processes resemble the nests of epithelioma. 

be used. Attention to the general health is of importance, and often a 
course of quinin, arsenic, or iron will be needed. 

Surgical treatment of vernal conjunctivitis is admissible in the tarsal 
type. The lid should be everted, and the growths should be cut off with 
scissors. The hypertrophies around the cornea have been excised, burned 
by the electrocautery, or destroyed by electrolysis, but the results have not 
been satisfactory. If a single tumor of the bulbar conjunctiva is present, 
it should be removed for diagnostic purposes. (Danvers.) Brossage is 
employed by some surgeons. 

Purulent Conjunctivitis (Purulent, or Gonorrheal, Ophthalmia; Oph¬ 
thalmia Neonatorum; Ophthalmoblennorrhea Neonatorum).—Ordinarily 
by these terms is meant an acute contagious conjunctivitis due to the gono¬ 
coccus of Neisser, occurring either in infants within a few days following 






DISEASES OF THE CONJUNCTIVA. 


2G3 


birth or in adults. In the former the disease is known as the ophthalmia 
of the newborn; in the latter it is called gonorrheal ophthalmia. It has 
been shown recently by Groenouw that the bacillus coli communis, asso¬ 
ciated with other microorganisms, was present in six of forty cases of oph¬ 
thalmia neonatorum. Bietti has reported a case of blennorrhea in a new¬ 
born child in which only the colon bacillus was found. The staphylococcus 
and streptococcus in exceptional cases are known to cause purulent oph¬ 
thalmia indistinguishable by clinical signs from mild cases caused by the 
gonococcus. Rapidly extending necrosis of the cornea with abundant 
purulent secretion may be due to infection by the Klebs-LoelHer bacillus in 
cases of localized diphtheritic conjunctivitis. In view of these facts it 
becomes necessary to modify the definition of ophthalmia neonatorum. 
The medico-legal importance of these observations should not be overlooked 
by the surgeon, who, in the absence of a careful bacteriologic examination, 
is not justified in making positive statements as to the etiology of a case 
of purulent ophthalmia. Hence the subject of purulent ophthalmia will 
be considered under these heads: (1) gonorrheal ophthalmia of the adult; 
(2) gonorrheal ophthalmia of the newborn; (3) purulent ophthalmia not 
due to the gonococcus. 

Gonorrheal Ophthalmia of the Adult.—This disease, which occurs more 
frequently in males than in females, is due to inoculation of the conjunctiva 
with secretion from a mucous membrane which is affected with inflamma¬ 
tion due to the gonococcus of Neisser. The pus from a vaginal or urethral 
gonorrhea, or the discharge from a gleet, is conveyed to the eye by such 
media as the fingers, handkerchief, towel, or washbowl. It is improbable 
that the gonococcus is carried by the air. Gonorrheal ophthalmia of the 
adult is always a serious disease. It is characterized by great swelling of 
the lids, a copious secretion of pus, a tendency to involvement of the cornea, 
and marked constitutional disturbance. 

Symptoms. —The period of incubation ranges from a few hours to 
three days. This is followed by the period of infiltration, lasting two or 
three days, which begins with the signs of an acute catarrhal conjunctivitis. 
Soon the eyelids become hard, swollen, and brawny, the upper lid often be¬ 
coming enormously enlarged and hanging over the cheek. The conjunctiva 
of the lids and fornix becomes much swelled, and often minute hemor¬ 
rhagic spots are seen inside the lids. The conjunctiva is hard, rough, and 
granular from infiltration of seroplastic lymph, and presents a deep-red, 
velvety appearance. The ocular conjunctiva is greatly swelled and forms a 
ring around the cornea (chemosis) and may protrude between the lids. 
During the acute stage the discharge is watery and sanious, and is streaked 
with flakes of mucus. There is great pain in and around the eye. The 
pre-auricular glands are tender and swollen and may suppurate. There is 
a rise of temperature, both local and general, and often the patient becomes 
much weakened by the inflammation. During this stage eversion of the 
lids is impossible without the outer canthus be cut. 


264 


MODERN OPHTHALMOLOGY. 


In the stage of purulent discharge the lids become less hard and tender, 
the secretions are distinctly purulent, and the inflammatory symptoms are 
less marked. Enormous quantities of yellow or yellowish-green pus ooze 
out of the conjunctival sac and flow down upon the cheek. This stage con¬ 
tinues for two or three weeks, and is succeeded by the stage of convalescence 
or papillary swelling. The conjunctiva may return gradually to the normal 
condition or may pass into a state of chronic blennorrhea, in which there 
is general redness and thickening of the membrane, with the presence of 
■enlarged papilke. The entire course of the disease lasts six or eight weeks. 

This disease presents various clinical pictures according to its severity. 
As a rule, the mildest cases are those due to gleet; the severest result from 
infection with pus from a violent gonorrhea, the discharge from the vagina 
or urethra being thick and yellowish. In severe cases a croupous deposit 
may be seen on the conjunctiva; in mild cases its surface is covered with 
flakes of lymph, which are easily detached. In the severest cases a deep 
infiltration exists like that which is seen in diphtheritic conjunctivitis. 

Etiology and Diagnosis.— The disease is due to the gonococcus of 
Neisser (Fig. 3, Plate IX), which occurs as a diplococcus and sometimes 
in a tetracoccus form. It is readily stained with aqueous solutions of anilin 
dyes, and is decolorized by Gram’s method. Chartres states that the serious 
ophthalmias are those produced by streptococci, or by streptococci and 
gonococci, or by a combination of these with other bacteria. 

The diagnosis of gonorrheal conjunctivitis is usually easily made by 
the history of the patient and by the symptoms described above; in case 
of doubt a bacteriologic examination should be made. 

Complications.— These are numerous, and may be immediate or 
remote. That which is most dreaded is corneal involvement. This structure 
may present a dull hazy look a few days after the commencement of the 
inflammation. Small oval ulcers form around the limbus. These may be 
comparatively clean or may be surrounded by a zone of infiltration; or 
large central idcers may be found. The corneal lesions may heal or may 
go on to perforation. They are due to two factors: pressure on the vessels 
and infection. Perforation of a central ulcer permits the escape of aqueous 
humor; the lens comes forward, closing in the opening, which is sealed by 
the deposition of lymph. Eeaccumulation of aqueous is then followed by 
reposition of the lens, which carries with it a tag of lymph, thus forming 
an anterior 'polar cataract. Sometimes the iris becomes adherent to the 
posterior surface of the cornea, producing the condition known as anterior 
synechia. If the perforation occurs in an ulcer situated peripherally, the 
iris is sure to become adherent in the scar following the healing process, 
and thus is established an adherent leucoma. Perforation may be followed 
by infection of the ciliary body and chorioid, ending in destruction of the 
eye by panophthalmitis, or in the slow shrinking of the globe, which char¬ 
acterizes phthisis bulbi. The inflammatory process weakens the cornea, 
and often the intra-ocular pressure, acting on such a softened structure, leads 


DISEASES OF THE CONJUNCTIVA. 


265 


to staphyloma (see “Cornea”). In a few cases iritis occurs apart from 
perforation. 

Prognosis. —The prognosis of gonorrheal ophthalmia, which is always 
a serious disease, will depend on the violence of the inflammation, the 
intelligence of the surgeon, the faithfulness of the nurse, and the character 
of the treatment. An incompetent surgeon will lose nearly all the eyes he 
treats; a competent one will occasionally have a bad result. In young 
persons the prognosis is more favorable than in elderly individuals. The 
greater the chemosis, the greater the danger of corneal complications. 
Marginal ulcers are not so serious as central ones. Much can be foretold 
by the appearance of the cornea. If it be cloudy early in the disease, the 
outlook is bad; if milky, the cornea surely will slough. Sudden pain in 
the course of gonorrheal ophthalmia means a perforation of the cornea or 
the establishment of iritis. If the eyeball is not perforated and lost, 
vision may be so much reduced by scarring of the cornea as to be practically 
valueless. 

Prophylaxis. —Whenever called to treat a case of gonorrhea the 
surgeon should warn the patient of the danger of infecting his eyes. If 
one eye is already infected, the other should be immediately sealed up by 
means of Buller’s shield, which is a watch-glass placed between two pieces 
of strong adhesive plaster or pieces of rubber. This is placed over the 
unaffected eye and is securely sealed above and on the nasal and temporal 
sides, leaving an aperture below for the air. Wherever possible, cases of 
gonorrheal ophthalmia should be isolated. 

Treatment. —It may happen that the surgeon gets his eye infected 
when examining a patient, or is present when the accident happens to 
another. In such an event the conjunctiva is to be washed out with boric 
acid solution, and a strong solution of nitrate of silver (gr. x-xxx to 
5 j) is to be applied to the membrane. This treatment may abort the dis¬ 
ease. It is applicable, however, only to the period immediately following 
the infection. 

The treatment of a case of gonorrheal ophthalmia will depend upon 
the stage of the disease. In the period of infiltration cold applications are 
useful. They should be applied day and night in this manner: Pieces of 
linen, or gauze, each two inches square and several layers in thickness, are 
to be placed on a cake of ice near the patient’s bed. Every two minutes 
the pieces are changed, the one removed from the eye being destroyed. 
In mild cases it will suffice to use this treatment only during the day. 
Pads of absorbent cotton can be used in place of linen. The patient’s bed 
should be narrow and capable of being approached from either side. The 
room should be well ventilated and scantily furnished. Vessels should be 
at hand for the collection and immediate destruction of all materials 
coming in contact with the discharge. 

Aside from the use of cold and attention to the general condition 
of the patient, there is little to be done in the acute stage. The bowels 


266 


MODERN OPHTHALMOLOGY. 


should be kept open. The pulse can be kept down by aconite or veratrum. 
When pain is severe one of the opium preparations should be used. Where 
the lids are greatly swollen a canthotomy will be in order. When this 
operation is necessary a general anesthetic should be given. With a pair 
of strong scissors the tissues at the outer canthus are to be cut down to 
the bone. The chemotic conjunctiva can then be felt. If hard, it is to be 
scarified in lines radiating from the cornea. This treatment relieves the 
blood-vessels and removes the pressure on the eye. The cul-de-sac can 
then be irrigated with warm boric acid (1 per cent.) or bichlorid solution 
(1 to 4000). 

In the stage of purulent discharge the chief indications for treatment 
are: ( 1 ) cleanliness and ( 2 ) the use of germicides and reducing agents. 
The cold applications are now discontinued and the surgeon aims to keep 
the pus from accumulating by cleansing the conjunctiva every half-hour 
or hour during the time that the secretion is abundant. This will require 
both a day and a night nurse. The eye is to be cleansed by gently sepa¬ 
rating the lids, mopping up the pus with absorbent cotton, and washing the 
cul-de-sac with a boric-acid solution by means of a pipette. Many ingenious 
instruments have been devised for lifting the eyelid and at the same time 
throwing a stream of water on to the conjunctiva. All such contrivances 
are to be avoided as dangerous to the cornea in the hands of all except 
possibly their inventors. The kind of antiseptic solution used is of little 
moment as long as it is not too strong. The chief indication* is to prevent 
the accumulation of pus. Boric acid (3 per cent.), bichlorid of mercury 
(1 to 15,000), or permanganate of potassium (1 to 5000) may be used 
with equal success. The solution chosen should be warm. 

' After the stage of infiltration is over and the lids can be gently turned, 
a germicide should be applied to the conjunctiva. The nitrate of silver 
(1 or 2 per cent.) solution has stood the test of time. It is used once 
daily, and need not be neutralized. Of late years protargol in 5- to 40- 
per-cent. strength solutions has been used by many ophthalmic surgeons. 
It does not possess any advantage over silver. The presence of a croupous 
membrane contra-indicates the use of silver. In such cases peroxid of 
hydrogen should be applied. In the last stage of the disease, when the 
papillary hypertrophies appear, the application of a weak solution of silver 
(gr. j to 5 j)> or the stick of alum, will be in order. 

The treatment of corneal ulceration is preventive and curative. The 
former includes canthotomy to relieve pressure on the globe, incision of 
chemosis to prevent strangulation of the minute vessels which ramify in 
the periphery of the cornea, and frequent cleansing of the conjunctiva to 
prevent accumulation of pus and infection of the cornea. The curative 
measures are the use of atropin (gr. iv to 5 j) thrice daily and the frequent 
washing of the ulcer with formalin (1 to 2000). The latter is the only 
antiseptic having the property of penetrating tissues. It is the aqueous 
solution of a gas (hence the bottle must be well stoppered), and is of great 


PLATE X, 

Extarnal Diseases af tha Eye, 









Fig i 1, 

Burn at Conjunctiva 
and Cornea, 



Fig. 2. 
Fannus. 



Fig, 3, 

Essential Shrinking of the 
Conjunctiva, (Cliver.) 




Fig. 5. Fig, S. 

Ophthalmia Neonatorum, Episcleritis. 



Fig. Z , Fig, a. 

Ulcer of the Cornea. Fascicular Keratitis. 














266 


MOD? KV 




OJLOGY. 


,e yT edjpto, 86.3^&3iC^ 1 i»^T;4xj3 ac0 njt<* or veratrmn. 

i to one of the opium preparations should be need. Where 
l ' .-it] swollen, a .-onthotomy will be in order. When this 
i v ary i »eral anesthetic Turn Id be given. With a pair 
>o tic • s at the outer can (bus are to be cut down to 
The cheriofk conjunctiva can then be felt. If hard, it is to be 

c; T, ri e'.n fro a the This treatn fofB^lieves the 

8 ' , ii;utnaU tc uinflt 

•'W^ s the pressure on i • • l r k#a 44 af-*bB-'‘?/e can 

rigahJ with warm boric acid (1 per-cent.) or bichlorid solution 

(1 to 4000 ). , 

(I) cleanliness and (2) the use of germicides and reducing agents. 

The t.-o;d applications are now discontinued and the surgeon aims to keep 

' o> ; - ; :• >m accumulating bv cleansing the conjunctiva every half-hour 

or • ur de ring the tin* that the secretion is abundant. This will require 

da and a night nurse. The eye is to b.e cleansed by gentlv sepa- 

ui> the pus with absoihent cotton, and .washing the 

b ,sn 


should he 
When pair 
the Jidt 
0;><T:»rk»i‘ 


■ * -srt 

entvUo/txrt-'raS TSiimtflBTlkiT 
(Emu-sisai ^p{i 


'wtnT a ' tr 




n.'OiriS " J ‘ 'atW itti 1 feriiijdiiSS'• r 0jSnd9asi9'.lS . 


!• *>n . the 




All such contrivances 
•• i oil- <»;' all 1 xc pt 
f,f •• |! - (,f PttiO 




■|1 CIO 




.2 .srr 

,Bin>igiq^lix2I 


a gerrme 

(1 or 2 
daily, an 
per-cent. strengtl - 
It does not possess any ■ .. 
membrane contra-ihe n u> •*- * 
hydrogen should be ap; • 
papiHan hypertrophies \> 

' :i to 5j). or the stick .■/>.. 

1 h* j treatment of corn* 
tV- > ■■ • • inel ad eg canthoton-.y : 

? - * to prevent strangulat 1 


,n. 


omen of the cornea, a: 


.a .srr >■ • 

.muiDir-'iuaVt sixulBiOdCi.n 

II gi *0118. 

■ e of a croupous 
1 . ich ases peroxid of 
>! disease, when the 
‘■aties a weak solution of silver 
m order. 

is ■ -v* rxpi\* and curative. The 
pressure on the globe, incision of 

a ■■ ' .. "> * li.-h '■ amifv in 

neat cleansing of the conjunctiva to 




ircuiiniffuon of ftus am 

.grttteit H isia3la^a r i 

of atropi! 


m a . lion of the corn#? : Bl ?i)e curative 

.BBiyioa Bill fa laartj 

the use oi atropm (jrr. it to 5j) thrice daily ami the frequent 
w-h »n ; .r iho ulcer with formalin (I to v<*'><>) The latter is the only 
anii-vptie having the property of penetrating tissues. It is the aqueous 
solut >u of a ga, (lienee the bottle must be \vi shoppe: d), and i* of great 


PLATE 10 










DISEASES OF THE CONJUNCTIVA. 


267 


value in the treatment of corneal ulceration. To prevent prolapse of the 
iris, in case a marginal ulcer shows impending perforation, eserin (Vio 
to 1 / 5 of 1 per cent.) is to be used, provided iritis is not present. Unfortu¬ 
nately this drug increases iris-hyperemia, and cannot be employed in iritis. 

Ophthalmoblennorrhea Neonatorum.—This is an acute inflammatory 
conjunctivitis occurring in the newborn, and is due to the gonococcus. 

Symptoms. —Usually on the second or third, less often on the fourth 
or fifth, day the infant shows a redness of the eyelids with a muco-purulent 
discharge. Slight redness of the conjunctiva is succeeded by great swelling 
of the lids, chemosis, and abundant purulent discharge (Fig. 5, Plate X). 
Generally one eye is infected first, and if promptly treated the process 
is much less severe in the second eye. The symptoms are the same as in 
gonorrheal ophthalmia of the adult, although in the case of the infant the 
process is less severe and corneal complications are less frequent. The chief 
danger is to the cornea. There is great swelling of the retrotarsal fold, 
and when the upper lid is everted the fornix comes into view as a red, rough, 
suppurating mass resembling granulations. In some cases, where the swell¬ 
ing of this fold is great, the upper lid becomes everted spontaneously when 
the child cries. 

Etiology. —The disease is due to inoculation by the gonococcus either 
while the child is passing through the maternal passage or shortly there¬ 
after. In a few cases it is evident that the infection must have occurred 
in utero, since the disease was present at birth. Strzeminski believes that 
the gonococcus can penetrate the intact fetal membranes. Infection is 
common in slow labors and in face presentations. Vaginal secretion, which 
is adherent to the eyelashes and lid-margins, may gain access to the con¬ 
junctiva when first the child begins to open and close its eyes. Eough at¬ 
tempts at washing may introduce the infection into the cul-de-sac. "There 
are cases of purulent ophthalmia in the newborn which are due to infection 
by bacteria other than the gonococcus, as will be explained later on. 

Diagnosis. —This should present no difficulty. Any redness or dis¬ 
charge about the eyes of an infant, occurring during the first week of life, 
is to be regarded as gonococcic infection unless bacteriologic examination 
shows the contrary. 

Prognosis. —While a serious disease, when recognized early and prop¬ 
erly treated few cases end in loss of the eye, although often the cornea is 
left with a small cloud. If the case is seen while the cornea is clear the 
prognosis is favorable, except in diphtheritic types or in those of general 
malnutrition. If not treated promptly and properly, SO per cent, of these 
cases will end in blindness, owing to the sloughing of the cornea. At the 
first visit the surgeon should examine the cornea, since the prognosis depends 
on its condition. 

Prophylaxis. —In no other disease have prophylactic measures met 
with such brilliant results. Vaginal antiseptics should be used before birth, 
and immediately after delivery the child’s eyes are to be washed with 


268 


MODERN OPHTHALMOLOGY. 


bichlorid solution (1 to 8000). Then a drop of 2-per-cent, strength solu¬ 
tion of silver nitrate is to be placed on each cornea. This causes consid¬ 
erable reaction, but prevents the disease. In three instances fatal bleeding 
from the conjunctiva has followed the prophylactic application of silver. 
The formation of small corneal opacities is of more frequent occurrence. 
The method described is particularly valuable in hospital practice and in 
private families where gonorrheal infection of the mother is suspected. 
A less efficient method of prophylaxis is the cleansing of the lids with a 
bichlorid wash and the irrigation of the conjunctiva with 5-per-cent, boric 
acid solution. Other prophylactic applications are protargol (20 per cent.) 
and perchlorid of mercury (1 to 3000). So important is prophylaxis by 
silver, which is known as Crede’s method, that in some foreign countries 
its practice is made obligatory by law. More than 30 per cent, of the 
inmates of German and Austrian asylums for the blind were rendered sight¬ 
less by ophthalmia neonatorum. Fuchs states that, of the 300,000 blind 
persons in Europe, 10 per cent, may be attributed to this disease. 

Treatment. —The same principles which govern the surgeon in the 
treatment of gonorrheal ophthalmia in the adult will obtain in this disease. 
Cleanliness is to be strictly observed. When suppuration begins, the everted 
lids are to be painted once daily with a 2-per-cent, strength solution of 
nitrate of silver. Where the granular masses are abundant, stronger solu¬ 
tions (4 to 8 per cent.) can be used until the flow of pus becomes less; 
then the weaker solution is used until the child is well. Strong solutions 
of silver must not be brought into contact with the cornea. Toward the 
latter part of the treatment a weaker solution (gr. ss to §j) is to be used. 
Corneal complications are to be treated as in the adult, except that the 
atropin solution must be a weak one (gr. 1 / 4 -j to §j). 

Non-gonorrheal Purulent Conjunctivitis. —Under this head it is pro¬ 
posed to describe briefly those cases of purulent ophthalmia presenting the 
clinical signs of gonococcic infection, in which the gonococcus is shown by 
bacteriologic examination to be absent. The importance of a demonstration 
of the presence or absence of the gonococcus is unappreciated by many sur¬ 
geons ; yet it has a direct bearing on questions of veracity and on the treat¬ 
ment. Grandclement states that if strong solutions of silver are used in 
non-gonorrheal purulent conjunctivitis the danger of corneal suppuration 
is increased. Myles Standish insists that in all cases of purulent conjunc¬ 
tivitis the diagnosis should depend on the bacteriologic findings, not on the 
clinical appearance. He states that ulcers of the cornea with very rapid 
necrosis may be due to the Klebs-Loeffler bacillus. In such cases diphtheria 
antitoxin gives favorable results as regards both the conjunctivitis and the 
corneal complication. Francisco, in a study of 40 cases of ophthalmia 
neonatorum, found the gonococcus in 30, and in several of the remaining 
cases the Ivoch-Weeks bacillus was present. The average duration of the 
gonococcic cases was 53 days; of the non-gonococcic cases, 36 days. Pari- 
naud mentions cases of conjunctivitis in the newborn in which there is 


DISEASES OF THE CONJUNCTIVA. 


269 


little pus, much lamination, and moderate palpebral injection. In these 
cases the pneumococcus is present. Groenouw found the bacillus coli com¬ 
munis in 6 of 40 cases of ophthalmia neonatorum, and Bietti has reported 
a case in which the colon bacillus was the only microorganism found. 
Haglund found the diplococcus intracellularis meningitidis in the conjunc¬ 
tival secretion of a boy whose eye was lost by a purulent inflammation. 
Recently, in St. Louis, several cases of purulent ophthalmia in babes have 
been shown to be due to the bacillus coli communis. 

Treatment. —In cases of non-gonorrheal purulent conjunctivitis the 
treatment will include cleanliness, the use of antiseptics, and attention 
to the general condition of the patient. If the Klebs-Loeffler bacillus is 
present the antitoxin of diphtheria is to be employed. 

Croupous Conjunctivitis (Pseudomembranous, Plastic, or Membranous 
Conjunctivitis). — This disease is characterized by the formation of an 
exudate on the conjunctiva, where it coagulates and forms a membrane. 

Etiology.— Croupous conjunctivitis is the result of many different 
causes, the, chief of which are bacterial, mechanical, or chemical. Among 
the bacterial causes are the Klebs-Loeffler bacillus, the streptococcus, the 
pneumococcus, the bacillus of Weeks, the gonococcus, and the xerosis bacil¬ 
lus. 

Loss of substance of the conjunctiva is followed by a fibrinous deposit 
under which healing progresses. This process is seen after wounds—as, 
for example, after tenotomy—and after injuries. A formation of false 
membrane folloivs the application to the conjunctiva of an irritant which 
may be organic (infusion of jequirity) or inorganic (ammonia, nitrate 
of silver in strong solutions). By painting the conjunctiva with ammonia 
Sourdille was able to produce at will either a croupous or a diphtheritic 
form of conjunctivitis, according as the strength of the irritant was varied. 
The same result can be had by the application of jequirity. There is. a 
relationship between croupous conjunctivitis and scrofula and eczema. Age 
is an etiologic factor, the disease having not been observed in the newborn 
and rarely among adults, while it is found in the majority of cases between 
the sixth month and seventh year. 

The relation of croupous to diphtheritic conjunctivitis has been the 
cause of much controversy. At the present time the views of Coppez, 
who finds that the symptoms, both local and general, gradually merge in 
the two affections, are accepted. Some cases diagnosticated as croupous 
conjunctivitis have been followed by fatal systemic infection, and others 
by post-diphtheritic paralysis. The croupous deposit on the conjunctiva 
may be present coincident with diphtheria of the throat, and in some 
cases of croupous conjunctivitis the true diphtheria bacillus has been 
found. Coppez’s view of the identity of these affections has been strength¬ 
ened by therapeutic tests. McQueen, in a case where the clinical diagnosis 
was croupous conjunctivitis, and the membranes which re-formed after 
removal were found to contain diphtheria bacilli, injected antidiphtheritic 


270 


MODERN OPHTHALMOLOGY. 


serum with success. Gossetti and Iona found the diphtheria bacillus present 
in 6 of 29 cases of croupous conjunctivitis. While the last word has not 
been said concerning the relationship of these types of conjunctival inflam¬ 
mation, it is necessary to distinguish clinically between the croupous and 
diphtheritic forms. 

Symptoms. —Croupous conjunctivitis presents itself as a mild or as a 
severe type. The mild form begins as an ordinary conjunctivitis followed by 
swelling of the lids, which are soft, pliable, and generally are not painful to 
the touch. The characteristic false membrane follows in a few days. It is 
formed in the fornices and tarsal conjunctiva, the bulbar portion of the mem¬ 
brane being exempt. The deposit is of a grayish-white, translucent, porce¬ 
lain-like appearance. When stripped off, it leaves a raw and perhaps a 
bleeding surface: a diagnostic point which serves to distinguish it from the 
diphtheritic form. The false membrane generally disappears in about two 
weeks. The signs of an ordinary conjunctivitis reappear and regeneration 
becomes complete. The cornea is rarely involved. 

A recurring form has been described in which the membrane is formed 
again and again, the process lasting for months or longer. 

The severe type of the disease, caused by streptococcic infection, shows 
great swelling of the lids, considerable discharge, and rapid destruction 
of the cornea due to the spreading of the exudation upon the bulbar con¬ 
junctiva. 

Diagnosis. —Croupous conjunctivitis may be confounded with diph¬ 
theritic and gonorrheal inflammations. In diphtheritic conjunctivitis the 
exudation, instead of being limited to the surface, involves the deeper 
layers of the conjunctiva. The bulbar portion of this membrane is involved 
and corneal ulceration is frequent. In gonorrheal conjunctivitis the dis¬ 
charge is much more purulent than in the croupous form. Croupous con¬ 
junctivitis is never found among the newborn. As a matter of fact, the 
diagnosis cannot be made in all cases by the clinical signs. Dependence 
can be placed alone upon the bacteriologic findings. 

Treatment. —The sound eye should be protected by a bandage or by 
a Buller shield. Nitrate of silver, protargol, and other irritants are posi¬ 
tively harmful in croupous conjunctivitis. Their use is not to be advised 
as long as the pseudomembrane is present. The local application of iced 
compresses; or, if the patient is feeble, the employment of hot applications, 
will be beneficial. The conjunctiva is to be washed three times a day with 
bichlorid of mercury (1 to 5000), boric acid, or a normal salt solution. 
Some surgeons report good results from sprinkling sulphate of quinin on 
the conjunctiva, and others use this remedy in the form of a lotion. After 
catarrhal symptoms have become established, weak solutions of silver can 
be applied cautiously. If the cornea is involved a bacteriologic examina¬ 
tion should be made. If the Ivlebs-Loeffler bacillus is found, diphtheria 
antitoxin should be used. Aristol has been recommended as a local appli¬ 
cation in croupous conjunctivitis with corneal ulceration. 


DISEASES OF THE CONJUNCTIVA. 


271 


Diphtheritic Conjunctivitis, which is rarely seen in the United States 
and in England, but is common in Germany and in some other Continental 
countries, is an extremely serious disease. It is a specific inflammation 
characterized by the formation of an exudate on and within the layers of 
the bulbar and tarsal conjunctiva. 

Symptoms. —Clinicians distinguish three stages: those of infiltration, 
suppuration, and cicatrization. In the stage of infiltration, which lasts 
from six to ten days, the initial symptoms are similar to those attending 
purulent ophthalmia, with the addition that pain is more severe in diph¬ 
theritic conjunctivitis. The lids are stiff and boardlike. The conjunctiva 
is of a gray or buff color, and is covered with an exudation. If this is 
stripped off, the surface beneath is of the same color, not red and bleeding 
as in croupous conjunctivitis. The bloodless condition of the conjunctiva, 
which is produced by coagulation of an exudate compressing the vessels, 
tends to produce necrosis, and this destructive process may advance so 
rapidly that the eye may be destroyed within twenty-four hours. There is 
danger of corneal necrosis at any time during the stage of infiltration. 
Patches of membrane are often found in the throat, and any excoriated 
spots about the cheeks, nose, or mouth readily become infected when brought 
into contact with the secretions. 

The stage of infiltration is succeeded gradually by that of suppuration. 
The lids become softer, the fibrinous exudate disappears, and the conjunc¬ 
tiva begins to look reddish, raw, and succulent. A purulent discharge is 
present. This stage ends and is followed by that of cicatrization. This 
leaves the conjunctiva atrophic and shrunken, with frequently great de¬ 
formity of the lids. Thus, trichiasis, entropion, sjunblepharon, and even 
exophthalmos may be produced. Involvement of the cornea, which is a 
frequent complication, assumes the form either of local ulceration or of 
diffuse infiltration. It is always secondary, there being no such process 
as primary diphtheria of the cornea. Coppez states that cases reported to 
have been primary diphtheria of the cornea were principally instances of 
corneal diseases from other causes in which the finding of the xerosis 
bacillus led to an incorrect diagnosis. The advent of corneal involvement 
causes great pain, and, as a rule, the process occurs early in the case. 

Etiology. —Diphtheritic conjunctivitis is due to the Loeffler bacillus 
(Fig. 2, Plate IX). The disease occurs chiefly in children between the 
ages of two and'eight years. Generally both eyes are involved. It may 
occur primarily, or may be secondary to nasal or faucial diphtheria. 

Diagnosis. —The chief clinical signs of croupous and diphtheritic 
conjunctivitis having been enumerated, it remains to be said that the 
diagnosis may be impossible without bacteriologic examination. Coppez 
states that there is a group of bacteria (the xerosis bacillus, the pseudo¬ 
diphtheria bacillus of Hoffmann, the bacterium septatum of Gelpke) which 
can be distinguished from the true diphtheria bacillus only by culture or by 
inoculation experiments. To make certain of the diagnosis of ocular diph- 


272 


MODERN OPHTHALMOLOGY. 


theria lie advises examination of cover-glass preparations, cultures on 
serum-agar, and the use of the Ernest-Xeisser double coloration. A com¬ 
petent bacteriologist can make these examinations and report the result 
the first day the case is seen. Owing to the general presence of the xerosis 
bacillus in the conjunctiva, the making of a microscopic examination of 
the discharge is less valuable here than in faucial diphtheria. 

Treatment. —In this disease both general and local treatment must 
be employed. Immediately the case is recognized as one of diphtheritic 
conjunctivitis, an injection of antitoxin must be given. The earlier this 
treatment is instituted, the less will be the danger of corneal sloughing. 
The injection should be repeated at the end of twenty-four hours. Im¬ 
provement should be noticeable at the end of a few hours. If the antitoxin 
is used later, the beneficial effect will be slow in appearing. When the 
antitoxin treatment is begun early the cornea can be saved in nearly all 
cases. 

Locally mild antiseptic washes are to be used. To protect the cornea 
from friction it will be advisable to place vaselin in the cul-de-sac twice 
daily. The sound eve should be covered with a Buller shield. 

Phlyctenular Conjunctivitis (Conjunctivitis Eczematosa; Scrofulous, 
Lymphatic, or Strumous Ophthalmia; Phlyctenular Ophthalmia).—This 
is a form of conjunctival and corneal inflammation occurring chiefly in 
children and characterized by eruption of phlyctenulas (Fig. 4, Plate X). 
These are accumulations of lymphoid cells, forming red elevations about the 
size of a millet-seed and situated upon the limbus of the conjunctiva. Soon 
the epithelium at the apex of the phlyctena separates, the underlying tissue 
becomes softened and breaks down, and thus a minute gray ulcer is pro¬ 
duced. Often the same process occurs simultaneously in the cornea. For 
this reason some ophthalmic writers have considered the disease in its 
entirety under one heading, devoting a separate chapter to it. The author 
will treat of phlyctenular conjunctivitis in this place, and of phlyctenular 
keratitis in the succeeding chapter, it being understood that no sharp line 
of demarcation can be drawn between these subjects. 

Etiology. — There is no general agreement as to the etiology of 
phlyctenular conjunctivitis and keratitis. Horner regarded the phlyctennke 
as merely ocular manifestations of eczema, and this view has been con¬ 
firmed recently by the studies of Sydney Stephenson. He found, among 669 
cases of phlyctenular affections of the eye, that in 355 (53.06 per cent.) 
eczema was present on examination, had been present previously, or is 
known to have appeared later. He demonstrated eczematous changes in the 
skin, in the nasal and buccal mucous membranes, and in the external 
auditory meatus. The phlyctenular diseases of the eye go hand in hand 
with tuberculous manifestations, such as swelling or abscess of the glands 
below the jaw, joint and bone lesions, otorrhea, dactylitis, pulmonary 
phthisis, and scrofulodermata. The occasional observation of phlyctenular 
conjunctivitis and keratitis in apparently healthy individuals may be ex- 


DISEASES OF THE CONJUNCTIVA. 


273 


plained, as Gradle states, by the assumption that a small tuberculous focus 
has been overlooked. Many writers assume that the active microorganism 
is the staphylococcus pyogenes aureus or albus, which is present under the 
affected epithelium. Phlyctenular ocular disease often follows measles or 
scarlatina. Rhinitis is always present, adenoid vegetations are common, 
and digestive disturbances often exist in these patients. In some cases 
hereditary syphilis is a factor. The disease is found chiefly between the 
fourth and fourteenth years, although it is occasionally seen in adults. 

Symptoms. —The subjective symptoms are pain, photophobia, lacrima- 
tion, and blepharospasm. The child avoids the light, hides in a dark 
corner, or buries its head in a pillow. Examination is difficult, owing to 
its struggles, and separation of the lids requires retractors. The child 
often presents a characteristic strumous appearance, being pale and thin, 
or flabby. Enlarged cervical lymphatic glands, adenoid vegetations in the 
pharynx, thick lips, eczema of the nose and upper lip, and purulent otitis 
media are often seen in these children. 

Inspection early in the case shows vesicles which form flattened 
prominences, measuring from 1 to 4 millimetres in diameter. They are 
of a grayish-red color and are surrounded by reddened conjunctiva. A few 
days later, the epithelium having been cast off, ulcers (phlyctenular ulcers) 
appear. These are smaller than the vesicles, because of a growth of epithe¬ 
lium from the periphery. The disease may present one or several phlyc¬ 
tenulas. After a variable time these heal and leave no scar on the con¬ 
junctiva. When appearing on the cornea a faint scar or deep cloud may 
remain, or the ulcer may perforate. In the multiple form the symptoms are 
generally much more complicated and relapses are common. The disease 
is not contagious. When a phlyctenular ulcer advances from the periphery 
toward the centre of the cornea, it is followed by a narrow band of vessels. 
The name fascicular keratitis (Fig. 8, Plate X) has been given to this 
condition. In phlyctenular conjunctivitis there is abundant lacrimation 
with little or no discharge. Eczema and blepharitis marginalis are often 
present. The life period of each phlyctena is from a few days to several 
weeks. 

Diagnosis. —Attention to what has been mentioned will prevent errors 
in diagnosis. In herpes of the conjunctiva, with which disease phlyctenular 
conjunctivitis may be confounded, the vesicles are transparent, appear in 
clusters, and do not show a predilection for the limbus. Furthermore, they 
are more transient. In spring catarrh the elevations are larger and do not 
ulcerate. Trachoma of the bulbar conjunctiva is associated with the same 
process in the conjunctiva of the lids and rarely involves the limbus. 

Prognosis. —Generally this is favorable, the disease yielding promptly 
to proper treatment. When the cornea is deeply involved scars will be left. 
A small number of cases will prove refractory to the most careful treatment. 
Localized infiltrates, not the phlyctenulas, are referred to here, the latter 
being transient lesions. 


18 


274 


MODERN OPHTHALMOLOGY. 


Treatment. —Recognizing that phlyctenular conjunctivitis is largely 
the local expression of a systemic disturbance, it will be the surgeon's duty 
to find the cause and remove it, while at the same time local treatment is 
to be employed. Errors of diet must be corrected, and it is well to exclude 
the sugars and starches, feeding the child on meats, milk, and oatmeal. 
The meals should be given with regularity, and eating between them or the 
use of miscellaneous articles of diet must be forbidden. The child with 
phlyctenular conjunctivitis or keratitis should not be kept indoors or in a 
darkened room. On the contrary, he should be compelled to obtain fresh 
air and sunlight. The eyes should not be bandaged. The skin should be 
kept clean and the bowels open. Often the use of calomel internally will 
improve the health. The palatable preparations of iron, codliver-oil, and 
of quinin can often be employed with benefit. The syrup of the iodid of 
iron, 20 or 30 drops three times a day after meals, is an accepted remedy. 
In those cases which do not respond to the general treatment just men¬ 
tioned, and the local measures to be described, the salicylate of soda should 
be used internally in large doses (gr. iij every four hours, for a child of 
five years). The effects must be carefully watched, depression and tinnitus 
being signals for the temporary interruption of the doses. If this treat¬ 
ment is not followed by improvement after a few days, it will be useless 
to continue it (Gradle). 

Locally the use of atropin is indicated. Where there is much irritation 
holocain can be used occasionally. If, as is generally the case, the child 
comes to the surgeon after the vesicles have burst, mercury should be used 
locally. There is probably no mercurial preparation more efficient than a 
properly prepared ointment of the yellow oxid (gr. j to oj). A small piece 
of this remedy is to be placed under the upper lid, once a day, by means 
of a probe. The eye is then to be massaged. Finely powdered calomel 
dusted on to the ulcers is an appropriate application. It should not be used 
if the patient is taking iodid of potassium internally, since the potassium 
iodid in the tears, uniting with the calomel, will form double iodids and 
cause irritation. The treatment with the yellow oxid must be continued for 
ten days after all signs of redness have disappeared. The patient’s refrac¬ 
tion should then be examined. In addition to the treatment outlined above 
it will be necessary to give attention to the concomitant lesions of the nose, 
ear, skin, pharynx, and lymphatic glands. In other words, the patient 
should be generally overhauled and all pathologic conditions -should be 
treated. 

Herpes of the Conjunctiva (Herpes Simplex). —Herpes of the con¬ 
junctiva, occurring apart from herpes zoster ophthalmicus, is a very rare 
affection. In it vesicles are found on the bulbar conjunctiva between the 
limbus and canthus. They appear in clusters and often the cornea is 
involved simultaneously. The disease occurs chiefly in adults. Photophobia 
and abundant lacrimation are marked symptoms. The intact vesicles are 
rarely seen, because they rupture early. They leave small ulcers to which 


DISEASES OF THE CONJUNCTIVA. 


shreds of epithelium are attached. The disease is to be distinguished from 
phlyctenular conjunctivitis by the description given above. It is to be 
treated by attention to the general health and by the use of the yellow oxid 
ointment. 

Papular Conjunctivitis.—A few cases have been recorded of papular 
conjunctivitis. Schreiber has described the case of a man, aged twenty-one 
3 T ears, who presented eroded papules on the genitals, and later similar 
papules appeared on the bulbar conjunctiva. The condition was considered 
phlyctenular until the presence of a peculiar efflorescence led to the em¬ 
ployment of specific treatment, under which the disease rapidly disappeared. 

Pemphigus of the Conjunctiva.—This rare disease, which was ob¬ 
served by Horner 3 times in 70,000 eye cases, is characterized by the devel¬ 
opment of successive crops of bulke. Pain, photophobia, and lacrimation 
are prominent symptoms. The disease is generally associated with pem¬ 
phigus of other parts of the body, such as the nose, mouth or throat, or 
skin. The bullae, which begin in the fornix or bulbar conjunctiva, rupture 
and leave grayish, ulcerated areas. These slowly cicatrize, causing shrink¬ 
ing and deformity. Meanwhile other bullae appear. Thus, the process 
continues for months or years. The conjunctiva becomes dry, meridional 
bands pass between the lids and the globe forming the condition known as 
symblepharon posterius, and in severe cases there is complete obliteration 
of the cul-de-sac (total symblepharon). Ulcers appear on the cornea, which 
becomes opaque and staphylomatous. Thus, vision is lost. The cause of 
the disease is unknown, and treatment is without avail. Arsenic may be 
given internally. Essential atrophy of the conjunctiva (Pig. 3, Plate X) 
seems to be due to pemphigus, although some writers describe it as an 
independent disease. 

Parinaud's Conjunctivitis (Lymphoma of the Conjunctiva).—This is 
a rare and peculiar form of conjunctival disease which has been studied by 
Parinaud, Gifford, Goldzieher, .Despagnet, and Dominique. It is charac¬ 
terized by the development of gigantic lynrph-follicles in the conjunctiva 
and by the presence of lymphomata in the neck on the same side as the dis¬ 
eased eye. The infection is supposed to be of animal origin, but this has not 
been proven and a specific microorganism has not been demonstrated. The 
disease begins suddenly with great thickening of the lids. There is a 
muco-purulent discharge, which may be abundant or scanty. Within the 
first 'week or two, large, polypoid, pedunculated granulations appear on the 
tarsi, in the fornices, on the ocular conjunctiva, or in all these places. 
Coetaneous with the conjunctivitis, the pre-auricular and retromaxillary 
glands swell and in some cases the cervical and submaxillary glands are 
similarly affected. The swelling may attain enormous proportions and 
suppuration frequently occurs. There are rigors and a rise of temperature. 
With one exception, in all the cases so far recorded, the disease has been 
unilateral. Spontaneous cure occurs in from two to six months, the dis¬ 
ease being rebellious to treatment. The visible granulations, which at first 


276 


MODERN OPHTHALMOLOGY. 


are red or grayish red, often hide smaller ones which are yellowish. They 
may become eroded. The prognosis seems to be favorable, since in only 
one of the reported cases has the cornea been involved. 

As regards treatment, Parinaud uses nitrate of silver, Abadie favors the 
galvanocautery, Gifford thinks that copper sulphate did good in a severe 
case which he treated, and other ophthalmologists have used iodoform oint¬ 
ment. Ablation of the granular masses has been recommended. 

Lithiasis of the Conjunctiva (TJratic Conjunctivitis).—This disease 
is characterized by a deposit of crystals of uric acid or sodium urate, in 
the acini of the Meibomian glands. The disease is associated with the gouty 
or rheumatic diathesis. Patients with lithiasis complain of a pricking 
sensation in the eyes and the feeling of a foreign body under the lids. 
Examination shows the deposits existing as numerous small concretions 
of a yellowish-white color. Both the palpebral and bulbar portions of the 
conjunctiva are hyperemic and the anterior scleral vessels are engorged. 
The disease is more common in elderly than in young subjects. It is proper 
to state that Herbert, who has carefully studied the conjunctival changes 
produced by chronic inflammation, considers “lithiasis,” “infarcts of the 
Meibomian glands,” and “mycosis” as cyst-formations sequent to the closing 
of epithelial tubules. The downgrowth of these tubules is found not only 
in papillary trachoma, but also in all forms of chronic conjunctivitis. The 
cheesy material found in these cysts results from the accumulation and 
degeneration of eqoithelial and wandering cells. The treatment consists in 
removing the crystallized masses with a cataract-needle under cocain anes¬ 
thesia. This treatment is to be followed by the use of a boric acid wash 
locallv and the internal administration of the salts of lithia. Attention 
to the general health is required in these cases. The disease is prone to 
recurrence. 

Egyptian and Military Conjunctivitis are terms which should be ex¬ 
cluded from ophthalmic nomenclature, since they have been applied indis¬ 
criminately to several different affections, among which are the gonorrheal, 
acute catarrhal, and trachomatous forms of conjunctivitis. 

Variolar Conjunctivitis.—Hyperemia of the conjunctiva usually accom¬ 
panies variola. About the fifth day of the eruption the conjunctiva may 
show a catarrhal form of inflammation which readily yields to simple treat¬ 
ment. The intensity of the conjunctivitis is in proportion to the involve¬ 
ment of the face and eyelids. Pustules rarely form upon the conjunctiva. 
When they occur they resemble phlyctenulas. A favorite site for the pus¬ 
tules is the area between the corneal margin and the inner or outer cantlius. 
Pustules may appear on the limbus, in which event corneal ulceration is 
likely to supervene. Chance states that pustules may form on the tarsal 
conjunctiva and on the caruncle, but are never found at the fornix. In 
the pustular type of variolar conjunctivitis severe inflammatory symptoms, 
such as chemosis and profuse discharge, are present. Subconjunctival 
hemorrhages may occur in hemorrhagic variola. 


DISEASES OF THE CONJUNCTIVA. 


277 


In the treatment of the conjunctivitis of variola mild antiseptic solu¬ 
tions should be used. 

Chronic Conjunctivitis is a common disease in the aged, and is char¬ 
acterized chiefly by hyperemia, swelling of the caruncle, hypertrophy of the 
papillary layer of the conjunctiva, and a scanty muco-purulent discharge. 
It may be the result of an acute catarrhal conjunctivitis, of an error of 
refraction, of lacrimal disease, of nasal inflammation, of excessive near 
work, or of unhygienic surroundings. The treatment includes the removal 
of the cause, abandonment of injurious habits (smoking, abuse of alcohol, 
etc.), correction of errors of refraction, and attention to the general health. 

Lacrimal Conjunctivitis.—This term is applied to those cases of con¬ 
junctival inflammation which are produced by the irritation of the dis¬ 
charge from an inflamed lacrimal sac. Various pathogenic germs are found 
in dacryocystitis, one of the most important being the streptococcus pyog¬ 
enes (Fig. 1, Plate IX). From contact with the irritating discharge, 
the caruncle and plica semilunaris become inflamed. The cause may be 
easily determined if the surgeon thinks to investigate the condition of the 
lacrimal apparatus. Often this examination is overlooked and the disease 
is classed as an intractable chronic catarrhal conjunctivitis. The prognosis 
will depend on that of the lacrimal disease. The cure of dacryocystitis will 
cause immediate improvement in the condition of the conjunctiva. If a 
corneal ulcer has been infected with the lacrimal discharge, the prognosis 
may be serious, such cases occasionally leading to deep ulceration of the 
cornea, with perforation and loss of the eye. 

Granular Conjunctivitis (Conjunctivitis Granulosa, or Trachomatosa; 
Egyptian Ophthalmia; Trachoma; Military Ophthalmia; Granular Lids). 
—This may be defined as a conjunctival inflammation (Fig. 3, Plate VIII) 
of long duration, characterized by the presence of trachoma bodies or granu¬ 
lations, and ending in cicatricial changes. In this disease, in addition to 
hyperemia and discharge, there are numerous grayish or pinkish-red bodies, 
which are about the size of a pinhead. These are particularly abundant in 
the conjunctiva of the upper lid and in the upper fornix, but also exist in 
the lower lid and in the bulbar conjunctiva. Trachomatous tissue may 
appear on the cornea. 

Etiology. —The disease originates in infection and produces an in¬ 
fectious purulent secretion. The identity of the microorganism causing 
it is unknown. Sattler, von Michel, and other ophthalmologists have de¬ 
scribed a small double coccus which can be cultivated from the contents 
of a trachoma follicle and which has been named the trachoma-coccus. 
Inoculation experiments with this coccus have not been productive. Pfeiffer 
and Eidley have described parasitic protozoa, and Muttermilch has written 
concerning a fungus named Microsporon trachomatosum, with whose pure 
cultures he claims to have produced trachoma in some of the lower animals. 
Other microorganisms—gonococci, streptococci, etc.—have been found in 
the discharge. 


278 


MODERN OPHTHALMOLOGY. 


The disease is spread by transfer of secretion from a trachomatous 
eye, the virulence of the process depending upon the quantity and quality 
of the discharge. The most dangerous epidemics are those characterized by 
an abundance of yellowish discharge. A trachoma which is kept in check 
by systematic treatment possesses slight power of contagion. The disease 
is common in places where many persons are crowded into small quarters 
and where unhygienic conditions exist, as in barracks, workhouses, orphan 
asylums, and schools. The agents concerned in passing infectious particles 
are numerous, and include such media as washing utensils, hands, hand¬ 
kerchiefs, bedlinen, medicine-droppers, etc. In foreign climes, where the 
heat is great, flies are the chief factors in spreading the contagion. Not 
age, but race, is an etiologic factor. Thus, trachoma is common among 
Hebrews, Italians, Egyptians, and other inhabitants of the East. The 
negro is almost exempt. The disease is common in Ireland. The geo¬ 
graphic distribution of trachoma is interesting. It is frequent in Arabia, 
Egypt, the eastern part of Europe, and the lowlands. Elevated areas, 
such as the Tyrol, Switzerland, and isolated mountain districts, where the 
altitude exceeds 6000 feet, are practically exempt. It is also of rare occur¬ 
rence in Scandinavia and in southern California. The disease is common 
in the western prairie districts of the United States, particularly in regions 
where sandstorms are frequent. Ziem states that the prevalence of the 
disease has kept pace with the destruction of forests and the consequent 
production of dust and sandstorms. It is supposed by Ivuhnt that nasal 
disease is an etiologic factor. It has been erroneously believed that trachoma 
was first introduced into Europe by Napoleon’s soldiers returning from 
Egypt in 1798. It is probable that eyestrain, by causing conjunctival hyper¬ 
emia, predisposes to the development of trachoma. The question whether 
malaria influences it is unsettled. Persons of the so-called scrofulous tem¬ 
perament are prone to the disease. 

Forms. —The subject of trachoma may fitly be considered under the 
following subdivisions: 1. Papillary trachoma. 2. Granular or chronic 
trachoma. 3. Mixed trachoma. 

1. The term papillary trachoma (papillary granulation or hyper¬ 
trophy) means that the papillae of the upper lid, more rarely of the lower, 
are enlarged and recognizable by the unaided eye. In mild cases the 
conjunctiva resembles sandpaper, while in severe ones it has been compared 
to a pile of velvet. It looks moist, red, and velvety. Early in the case 
lacrimation is profuse. Later a muco-purulent or purulent discharge ap¬ 
pears. The conjunctiva is injected, the papillae are enlarged, and the 
characteristic granulations are scattered through the membrane. After a 
variable period the disease subsides. In favorable cases a cure results, the 
granulations being absorbed and a smooth conjunctiva remaining. In other 
patients there are indications of scar-tissue in the mucous membrane, or 
the disease may pass into the chronic form. 

2. Granular or chronic trachoma generally is chronic from the begin- 


DISEASES OF THE CONJUNCTIVA. 


279 


ning, but in some cases it results from the imperfect disappearance of the 
papillary form. The characteristic feature is the presence of the trachoma 
granules. These are round, opaque bodies, of grayish-white color, measuring 
about two millimetres in diameter. They are deeply set in the conjunctiva 
and are often confluent, thus forming areas of trachomatous material. They 
may be scattered over the whole conjunctiva, but are particularly numerous 
where the adenoid tissue is abundant: i.e., in the fornices, especially the 
upper one. The conjunctiva may be hyperemic or anemic. There is gen¬ 
erally a slight mueo-purulent discharge. The eyes burn and smart, near 
work becoming difficult, particularly at night. The disease may continue 
thus insidiously for many months, when suddenly an attack of acute in¬ 
flammation ensues and the picture changes to that of acute inflammatory 





Fig. 211.—Trachoma follicles. (Author.) 

(Photomicrograph by Dr. H. P. Wells.) 


trachoma. Eedness, pain, lacrimation, photophobia, discharge, blepharo¬ 
spasm, corneal inflammation and ulceration, and rapid loss of vision are 
now important symptoms. Acute inflammatory trachoma is simply tra¬ 
choma to which an acute conjunctivitis has been added. 

When, in the quiet form, the lids are everted, the characteristic granu¬ 
lations appear as sago-like elevations which are arranged in rows and are 
particularly prominent in the fornices. A few isolated trachoma bodies may 
be seen in the bulbar conjunctiva. The membrane is rough, and does not 
show the velvety appearance found in the papillary variety. After the 
advent of inflammatory symptoms the membrane shows swelling of the 
papillae, which may obscure the granulations. They may be absorbed, but 
generally new trachoma bodies appear, and thus the disease continues in¬ 
definitely. After a variable period grayish-white bands of connective tissue 




280 


MODERN OPHTHALMOLOGY. 


are to be seen, marking the appearance of the stage of cicatrization. Thus 
the disease improves at the expense of the normal conjunctiva, which is 
replaced by scar-tissue. In this stage the tarsal plates become deformed, 
producing trichiasis, entropion, and corneal ulceration. The conjunctiva is 
converted into a pale, bluish-white, atrophic membrane, and the fornices 
are much reduced in size or are entirely obliterated. 

3. Mixed trachoma is a common condition, the papillary and granular 
forms being present simultaneously. The papillary form involves chiefly 
the tarsal conjunctiva, while the granules develop luxuriantly in the 
fornices. 

Complications and Sequela?. —The chief complications of trachoma 
are corneal ulcers and pannus. Corneal ulcers may appear at a place where 
the cornea is normal or in connection with pannus. The nature of these 
ulcerations does not demand special attention in this place. Pannus (Fig. 
2, Plate X) consists in the formation of a new growth of connective tissue 
which is situated between the epithelium and Bowman’s membrane and is 
provided with blood-vessels. This new tissue presses its way from the 
periphery toward the centre, and corresponds chiefly to that part of the 
cornea in relationship with the upper lid. Pannus may disappear entirely, 
or the enlarged vessels may shrink, leaving small radiating lines to mark 
the spot where they existed. If ulceration is associated with pannus, the 
cornea will likely remain clouded in its upper part. Buller has seen cases 
of trachoma associated with ichthyosis. 

Among the sequel® are trichiasis and entropion. Normally the margin 
of the lid, at the point where the conjunctiva and skin unite, forms a right 
angle. In trachoma it is worn away, and the eyelashes, being given a wrong 
direction (trichiasis), rub on the cornea, producing constant irritation. 
The contraction of the newty formed connective tissue leads to thickening 
and incurvation of the tarsal plate ( organic entropion. Fig. 6, Plate VII) 
with trichiasis. Continuance of either condition leads to corneal inflam¬ 
mation and ulceration. The lower eyelid often turns outward as a result 
of trachoma. The thickened conjunctiva presses the lid-margin away from 
the globe and contraction of fibres of the orbicularis muscle completes the 
eversion ( spastic ectropion. Fig. 5, Plate VII). When atrophy of the 
conjunctiva has become marked, the folds in the fornices disappear and the 
mucous lining of the lids passes directly into that of the globe (posterior 
symblepliaron). In excessive atrophy the conjunctiva is converted into a 
dry, tough membrane (xerosis); the cornea suffers at the same time, be¬ 
coming cicatricial and opaque. In the course of trachoma in the Malay race, 
and also among the Chinese, Steiner observed pigmentation of the con¬ 
junctiva in the form of irregular dots and lines. The spots, which are 
found most frequently on the upper lid, are black. They are without 
pathologic significance. Among the most important sequel® are the corneal 
changes, which include: (1) the formation of scars, following ulceration, 
by the transformation of pannus into connective tissue; and (2) the 


DISEASES OF THE CONJUNCTIVA. 


281 


alterations in curvature, which may be slight or may produce a decided 
bulging of the membrane (ectasia of the cornea). Thus it is seen that 
trachoma, by reason of its complications and sequelae, is one of the most 
important of ocular diseases. 

Pathology. —As regards the nature and origin of the changes found 
in trachoma there is much dispute. Iwanoff, Berlin, and others contend 
that there is a new product, while Sattler, Raehlmann, and Vincentiis 
believe that there is simply a change in the normal tissue. Burnett states 
that the process is probably a combination of both. Attempts which have 
been made to distinguish histologically between follicular conjunctivitis 
and trachoma have not been successful. Herbert believes that the difference 
is in the amount of material present in the two types. He states that in 
follicular conjunctivitis and trachoma, in addition to an increase in the 
number of large plasma-cells (rounded cells modified from connective- 
tissue cells in chronic inflammation) which are distributed through the 
conjunctiva, there is an hypertrophy of existing follicles and lymphoid 
tissue, with a new formation of these structures. The changes in trachoma 
begin in the lymphatic spaces of the lymph-vessels. Such a collection of 
cells, encapsuled by vessel-walls, by growth gives origin to a follicle. Com¬ 
monly the follicles are formed by the continued addition of cells grouped 
in lymph-spaces and lymph-vessels. Absorption of follicles, according to 
the same authority, takes place in various ways: 1. The cells are carried 
away in the lymphatics. 2. Other cells become ameboid and travel through 
the surface epithelium or into the blood-vessels. 3. Others undergo vacuolar 
or hyalin degeneration. The trachomatous process involves all parts of the 
conjunctiva, except the ocular portion near the cornea and a narrow strip, 
three millimetres broad, next to the lid-borders. These parts normally 
are covered by stratified squamous epithelium. As regards the hypertrophic 
changes, there is an extension of surface by the formation of papillae and 
an increase of epithelium in epithelial downgrowths. These epithelial 
tubules often lead to the formation of cysts possessing yellowish and cheesy 
contents. In the stage of atrophy there is a disappearance of areas of the 
normal fibrous and elastic matrix of the conjunctiva, with the formation 
of scar-tissue. The development of papillae is not characteristic of trachoma, 
since they may attend any type of conjunctivitis of considerable-duration. 

Diagnosis. —The diagnosis of trachoma generally presents little diffi¬ 
culty. Such diseases as chronic catarrhal conjunctivitis, vernal catarrh, 
and the papilliform swellings of purulent conjunctivitis have been suffi¬ 
ciently described and will not embarrass the careful observer. Between the 
false, or follicular, granulation and the true, or “sago-grain,” granulation 
differentiation may sometimes be difficult. The chief characteristics of 
these affections, which are different clinically, but not histologically, are 
given by Stephenson as follows:— 


282- 


MODERN OPHTHALMOLOGY. 


Follicular, or False, Granulation. 

1. Oval or roundish, transparent bod¬ 

ies, the diameter of which seldom 
or never exceeds 1 or 1.5 milli¬ 
metres. They often possess a 
faint-yellowisli hue, and are 
usually arranged in rows. Their 
tendency is to remain discrete: 
that is, separate from one another. 
They are always larger in the in¬ 
ferior fornix. 

2. Seldom are associated with much 

change in the structure of the 
conjunctiva. 

3. Papillary hypertrophy of the upper 

lid is trivial. 

4. The tarsus is not implicated. 

5. The growths disappear spontane¬ 

ously without forming scar-tissue. 


G. No drooping of the upper lid. 

7. Pannus and corneal ulcers are ab¬ 

sent. 

8. Trichiasis, entropion, and shrinking 

of the cul-de-sac do not occur. 

9. Occurs chiefly in persons under 

twenty years of age. 

10. Not contagious. 


“Sago-grain,” or True, Granulation. 

1. Pound, opaque, ill-defined bodies of 

grayish-white color and extreme 
friability. Firmly and deeply im¬ 
bedded in the conjunctiva, their 
diameter often reaching 2 milli¬ 
metres or more. They tend to 
become confluent, thus forming 
areas of trachomatous material. 
They are always larger and more 
numerous in the upper fornix. 

2. Structural changes are always pres¬ 

ent in the conjunctiva. 

3. Papillary hypertrophy of the upper 

lid is marked in many of the cases. 

4. The tarsus is often involved. 

5. Spontaneous cure occurs only with 

the onset of scarring, which may 
be slight or extensive according 
to the degree of development of 
the original granulations. 

6. Upper lid droops in most cases. 

7. Pannus and corneal ulcers occur in 

at least 25 per cent, of the cases. 
S. Trichiasis, entropion, and shrinking 
of the cul-de-sac occur very fre¬ 
quently. 

9. May occur at any age. 

10. Conditionally contagious. 


Prognosis.— When seen early and treated persistently the prognosis 
of trachoma is favorable. Corneal ulceration and pannus often give better 
results than would be expected, although vision is often reduced. Trichia¬ 
sis and entropion can be relieved by operative treatment. In the stage of 
atrophy treatment is of little use. Unfortunately persons with trachoma 
often cease treatment too soon, and under such circumstances they are sure 
to suffer a recurrence. Such cases often end in blindness or in serious 
reduction of vision. A trachomatous eye is always liable to attacks of 
acute inflammation in response to a fresh irruption of trachoma follicles 
or to external irritants. 

Treatment.— The treatment of trachoma is prophylactic, medical, 
and surgical. When possible these cases should be isolated. In private 
practice each patient should have his own towels, soap, washbowl, and 
handkerchiefs. In asylums and schools the lavatory arrangement should 
include what is known as the "jet system,” which makes it impossible for 
the same water to be used by more than one person. Cleanliness is always 
in order in trachoma. Hot water and Castile soap are probably as efficient 
as any of the numerous antiseptic washes. 




DISEASES OF THE CONJUNCTIVA. 


2S3 


The medical treatment may be formulated as follows: In acute in¬ 
flammatory attacks cleanliness, hygienic measures, and atropin are to be 
employed until the pain and inflammation have subsided. Then once daily 
the conjunctiva of the lids and fornices is to be painted with a solution 
of nitrate of silver, of the strength of 2 or 3 grains to the ounce, until the 
secretion ceases. If the cornea is involved atropin is to be used once or 
twice a day. This treatment should be continued week after week, but it 
must not be kept up indefinitely, because of the danger of producing 
argyrosis. In applying the silver solution the surgeon should see that it 
reaches the folds in the upper fornix. Caustics are absolutely to be es¬ 
chewed in this as in every other form of conjunctivitis. What is wanted 
is stimulation of the absorbents, not destruction of the membrane. In many 
lands, after the secretion has diminished, a stick of lunar caustic or copper 
sulphate is employed. Schiele uses the solid stick of iodic acid, and claims 
that it does not cause a scar. Hesnamoff employs a 1- or 2-per-cent, 
strength solution of iodin in liquid petrolatum. Seabrook commends this 
treatment in chronic cases with little secretion. Ichthyol in 10- or 20- 
per-cent. strength solutions has found favor with some ophthalmic sur¬ 
geons. In the hands of many practitioners copper and other caustics are 
positively harmful. When used they are to be employed simply as irritants, 
not as escharoties, and their application will not be in order until after 
the discharge has practically ceased. Instead of copper, a stick of alum 
can be used as a stimulating agent. It is possible, as Thompson has 
remarked, that trachoma is a much different disease in the Mississippi 
Valley from that type found in some far-distant place, and that the treat¬ 
ment should vary accordingly. As the case improves under the treatment 
outlined, the period between the applications can be lengthened and the 
patient can make use of a collyrium of sulphate of zinc, boric acid, protargol, 
or argyrol. The use of a 3- to 10-per-cent, strength ointment of citrate of 
copper in white vaselin is recommended by Wright, of Mobile. He states 
that it produces absorption of the granulations, is non-irritant, and can be 
used by the patient. 

Under medical treatment. improvement of trachoma is often a slow 
process. Hence various surgical measures have been advocated, and many 
of these are of great antiquity. Among those worthy of mention are scari¬ 
fication, expression, brossage, grattage, excision of individual granulations, 
excision of the cul-de-sac, the application of the galvanocautery and electrol¬ 
ysis, or the use of the x-rays. These measures, as a rule, are to be em- 
ployed only in cases in which acute symptoms are absent and which resist 
medical treatment, although some eminent authorities prefer them to med¬ 
ical measures. The objection to most surgical procedures is that the scar 
resulting from the operation may more than offset the good derived from 
the operation. Of the surgical procedures, the least objectionable is ex¬ 
pression. This can be done in various ways, but the use of the roller 
forceps is preferred. The instrument is used to express the contents of 


284- 


modern OPHTHALMOLOGY. 


the trachoma follicles, and this is accomplished rapidly and safely under 
local or general anesthesia. Expression may be used alone or it may be 
combined with scarification of the conjunctiva and the local use of a 
germicide which is rubbed into the tissues by means of a stiff brush. The 
author prefers expression used alone and followed immediately by cold 
compresses. Later for several weeks a solution of nitrate of silver is to 
be applied. In using expression care must be taken to press out the 
trachomatous material in the region of the fornices and canthi. Stephen¬ 
son, Walsh, and Mayou have recently reported favorably on the treatment of 
trachoma by x-ray tube exposure. 

Pannus generally clears up pan passu with the improvement in the 
conjunctiva, but in some cases, in which there is a formation of dense 
connective tissue, it may require special treatment, such as the use of 
jequirity or the performance of periectomy. Jequirity, which was intro¬ 
duced into ophthalmic practice by de Wecker, is employed to set up a 
violent corneal inflammation in the hope that with its subsidence the pannus 
will disappear. It is used in an infusion (3 to 5 per cent.) applied to the 
everted lids, or the powdered drug may be dusted on to the conjunctiva. 
The latter method is highly recommended by Cheatham. The jequirity 
treatment must be used with caution, since some cases have been reported 
in which its employment was followed by destruction of the cornea. In 
many cases it has a curative effect on pannus. 

Landolt and Holmes have reported good results from the treatment 
of pannus by boric acid and massage. The everted upper lid is dusted with 
the powder and then the eyeball is massaged with the lid intervening, a 
local anesthetic having been previously applied. 

Since pannus is a corneal complication of a circumcorneal disease, the 
excision of a piece of conjunctiva adjacent to the cornea has been done for 
the purpose of producing an area of cicatricial tissue, which shall act as 
a safeguard against invasion. Boeckmann, who has had an extensive 
experience with this operation (periectomy), regards it as a harmless and 
efficient treatment for pannus. 

Vaccinia of the Conjunctiva is of rare occurrence, and is characterized 
by violent redness and swelling of the affected membrane. The infection 
is carried by unclean fingers and runs the course of vaccinia. It tends to 
recovery and calls for little treatment. 

Varicella of the Conjunctiva has been described by Hilbert. 

Conjunctivitis Petrificans (Acute Calcification of the Conjunctiva).— 
In 1893 Leber described this rare disease, which is characterized by the 
presence in the conjunctiva of lime in organic, crystallizable combination. 
The lesion appears as white, opaque spots, with slight or no inflammatory 
and subjective symptoms. The disease spreads spasmodically, new foci 
appearing while others are healing, the process lasting for months or years. 
The smaller foci vanish by absorption, while the larger ones leave shriveled, 
thickened spots in the conjunctiva. In some cases the disease produces 


DISEASES OF THE CONJUNCTIVA. 


285 


blindness through corneal involvement. When it is possible to do so, the 
foci are to be excised. 

MISCELLANEOUS DISEASES OF THE CONJUNCTIVA. 

Ophthalmia Nodosa (Raupenhaar-ophthalmie) is due to the entrance 
of caterpillar-hairs into the conjunctiva or cornea and iris. The disease 
is characterized by intense pain and the appearance of nodules in the tissues 
involved. Lacrimation and photophobia are present. Violent inflammatory 
symptoms supervene some weeks or months after the receipt of the injury, 
and iritis and iridocyclitis are frequent complications. Where nodules are 
found in the iris the disease may simulate tuberculosis. Often careful and 
repeated examinations are necessary before the hairs can be found. Ex¬ 
cision of the nodules and the continued use of a mydriatic are called for. 

Filaria.—In addition to the cysticercus an entozoon known as Filaria 
loa has been observed beneath the conjunctiva. The parasite occurs among 
the natives of the west coast of Africa and in persons who have visited this 
region. The worm varies from twenty to seventy millimetres in length and 
is about one-half to one millimetre broad. It is round, firm, transparent, 



and colorless. By its movements beneath the conjunctiva or under the skin 
of the eyelids it keeps the eye irritated. The treatment is wholly surgical. 
The worm should be removed through a conjunctival incision. 

Pterygium (Fig. 7, Plate VIII) is a fleshy and vascular growth, 
triangular in shape, springing from the conjunctiva, generally of the outer 
or inner canthus, and extending to the cornea, with which it is united. 
It is frequently located over the course of the internal rectus muscle. The 
same eye may present two pterygia, one on the nasal, the other on the 
temporal, side; and the two may meet in the centre of the cornea. In rare 
instances pterygium is foimd growing from the centre of the lower or 
upper eyelid, as in Fig. 213. If of recent origin, the growth will appear 
reddish and succulent (pterygium crassum) ; if somewhat old and atrophic, 
it will appear thin and membranous (pterygium tenue). The disease may 
remain stationary or may become progressive, rapidly encroaching upon 
the cornea. In the course of years it may completely cover the cornea and 
thus do great damage to vision. The conjunctiva forming the pterygium 
may be tense, and thus the plica semilunaris may be obliterated. Such 


286 


MODERN OPHTHALMOLOGY. 


growths often cause irritation by the constant tension ancl may even limit 
the action of the ocular muscles. A pterygium often will become irritated 
and inflamed, particularly in the summer, when dust is abundant. 

Etiology. —Pterygium, while generally found in adult and middle 
life, is occasionally seen in young persons. It is common among farmers, 
thrashers, ranchmen, teamsters, stonecutters, and other persons who are 
much exposed to the elements. Heat, a dry atmosphere, high winds, ex¬ 
posure to sunlight, and the irritating effect of alkaline dust are etiologic 
factors/ The disease is much more frequent in the southwestern than in 
other portions of the United States. It begins either in degenerative 
processes following on pinguecula—this growth pulling the conjunctiva 
on to the cornea, where it becomes attached—or it follows upon a small 



Fig. 213.—Traumatic pterygium. (Oliver.) 

ulceration at the margin of the cornea. Savage believes that Fuchs’s view 
that pterygium originates from pinguecula is incorrect. 

Pathology. —Histologic examination shows that a pterygium is sim¬ 
ply an hypertrophy of the conjunctiva which involves the epithelial and 
anterior elastic layers of the cornea. 

Prognosis. —If the pterygium has encroached upon the pupillary 
area of the cornea, there will be diminution in vision after the excision 
of the growth. If the entire cornea is covered, the removal of the pteryg¬ 
ium will improve vision, but normal vision should not be expected. In 
general, it may be said that the prognosis in cases of pterygium is favor¬ 
able. The condition may return to a less extent than before operation. 

Treatment. —Medicines are useless in the treatment of pterygium; 
operation alone is valuable. The growth should be transplanted or excised. 


DISEASES OF THE CONJUNCTIVA. 


287 


The old operation of ligation, which is barbarous and unscientific, should 
not be performed. The surgical management of this disease will be dis¬ 
cussed in the latter part of the present chapter. In extensive pterygia, 
which cover a large part of the cornea, it may be advisable not to disturb 
the growth, but to perform iridectomy. Fortunately these neglected cases 
are seldom encountered. Eemoval of a pterygium is followed by increased 
haziness of the cornea, due to inflammatory action, and often this cloud dis¬ 
appears slowly. The best visual result does not always come immediately. 
Ophthalmometric examinations show that the corneal curvature is altered 
by the pterygium, and after its removal search should be made for astig¬ 
matism. Pterygium causes astigmatism in two ways: by lifting up the 
superficial corneal layers and by traction. Patients from whom pterygia 
have been removed often complain that the growths have returned. In a 
measure, this is true, but the secondary growth is smaller, and consists 
chiefly of blood-vessels which are necessary to the reparative process in the 
cornea. 

Pseudopterygium (Cicatricial Pterygium) is the name applied to the 
fixation of a fold of conjunctiva upon the cornea as a sequence of inflam¬ 
matory action. This may result from trauma by heat or caustics, or may 
follow operations for the removal of conjunctival growths. In some in¬ 
stances pseudopterygia develop after chronic superficial ulceration of the 
margin of the cornea. In other cases they are sequent to a chronic blen- 
norrheic or to a diphtheritic process. A true pterygium ordinarily permits 
the passage of a sound beneath its folds at the limbus, while in pseudo¬ 
pterygium this cannot be done. In the former the growth generally is 
progressive, while pseudopterygia remain fixed at the part of the cornea 
to which they originally became attached. Small pseudopterygia may be 
permitted to remain; large ones should be excised. There is a rare form 
of false pterygium named pterygo-symblepharon, which is characterized by 
adhesion between the lower lid and the cornea through an intervening flat, 
vascular band of conjunctiva. 

Pinguecula is a small, yellowish growth of the bulbar conjunctiva, 
adjacent to that part of the cornea corresponding to the interpalpebral 
fissure. It looks like a piece of fat, but is considered a hyalin degenera¬ 
tion of the conjunctiva and subconjunctival tissue, associated with an 
hypertrophy of the elastic fibres of the conjunctiva. It is rounded or 
triangular in shape, and is found in adults who are exposed to irritating 
influences. Fuchs considers that pterygium originates from pinguecula, 
but Ivnapp holds that this statement is too sweeping. Pinguecula is gen¬ 
erally non-progressive and rarely calls for treatment. It can be excised 
or destroyed by means of the cautery. 

Amyloid Degeneration of the Conjunctiva.—This rare disease, which 
was first described by Oettingen, of Dorpat, has been observed principally 
in Russia. The conjunctiva becomes hypertrophied, often projects between 
the lids, and is yellowish, wax-like, non-vascular, and friable. The disease 


2S8 


MODERN OPHTHALMOLOGY. 


generally begins in the retrotarsal folds and invades the bulbar and pal¬ 
pebral portions of the conjunctiva as well as the caruncle. The eyelids are 
much thickened, and, when drawn forcibly apart, the wax-like conjunctiva 
is seen surrounding the cornea, which is usually clear, but may show pannus. 
The swollen tissue is friable, and often breaks when the lids are held apart. 
The disease often lasts for years without inflammatory symptoms, and the 
patient cannot see because of inability to open the lids. There is no 
discharge or lacrimation, and pain is absent. The affection is as frequently 
unilateral as bilateral. The cases so far reported have occurred in adults. 
Some writers have claimed that a relationship exists between trachoma 
and amyloid degeneration; but this view is not now accepted. The disease 
has nothing to do with amyloid degeneration located in other organs or 
tissues. 

The first step is an hypertrophy of the conjunctiva. This is followed 
by an increase of the adenoid elements, and later there is a hyalin degen¬ 
eration, which is followed by the appearance of amyloid bodies. Finally, 
calcification and ossification occur. Hyalin and amyloid degeneration look 
so much alike that differentiation can be obtained only by examining 
excised pieces of tissue. Calcification or ossification of the diseased con¬ 
junctiva may occur in these cases. In a doubtful case the diagnosis can 
be made by means of the iodin test. Treatment is of little value. Excision 
may be of benefit. 

Xerosis (Xerophthalmos; Atrophy of the Conjunctiva).—In this con¬ 
dition the conjunctiva becomes thick, dry, and of a whitish color resem¬ 
bling skin. An analogous process is observed in the cornea. Xerosis of 
the conjunctiva appears either sequent to a local disease or as an accom¬ 
paniment of a general affection. Locally it occurs after cicatricial degen¬ 
eration following trachoma, pemphigus, burns, or diphtheritic conjunctivitis 
(parenchymatous xerosis ); or it may be due to insufficient protection, 
as in ectropion and lagophthalmos, the exposed conjunctiva becoming cov¬ 
ered with a thick, epidermoid epithelium (epithelial xerosis). Resulting 
from a general disease, conjunctival xerosis occurs in a light and also in a 
severe type. The former accompanies nyctalopia, while the latter is found 
in cases of keratomalacia. A special bacillus (xerosis bacillus) has been 
described. According to Fuchs, it is neither the cause of xerosis nor char¬ 
acteristic of this disease, since it is found in the healthy conjunctival sac. 

In the primary type the part of the conjunctiva corresponding to 
the palpebral opening shows a froth-like deposit (composed of degenerated 
epithelium), which is triangular in form, the base being toward the cornea. 
The conjunctiva is anesthetic and irritation fails to produce lacrimation. 
In severe cases the cornea becomes dull and opaque and may slough. An 
important subjective symptom is night-blindness. The disease is common 
in Brazil and among the negroes of the South. Prognosis is unfavorable. 

Treatment. —Primary xerosis of the conjunctiva is found chiefly 
among the ill nourished and calls for supportive and tonic treatment. 


DISEASES OF THE CONJUNCTIVA. 


289 


Local treatment is of little value. Glycerin and water, an emulsion of 
codliver-oil, or white vase]in may be used as local applications with comfort 
to the patient. 

Tuberculosis of the Conjunctiva.—Since Koster, in 1874, described 
this disease (Fig. 8, Plate VIII) many cases have been recorded; but the 
bacillus of .tnbercle has been recognized as the cause only since 1882. It 
is a rare affection, Eyre having met with it in 8 out of 25,000 new oph¬ 
thalmic cases in London. It may be primary, but is generally secondary 
to nasal or laryngeal tuberculosis. An abrasion from a slight trauma or 
the breaking of a conjunctival phlyctenula furnishes a nidus for the growth 
of the bacillus which can be carried to the raw surface by particles of dust, 
towels, fingers, or by unclean instruments used in tenotomy operations. 
The youngest case occurred in an infant of ten months, the oldest in a man 
of thirty years. Most cases occur at or about puberty. Females seem to 
be more liable than males in the proportion of 1.5 to 1. The palpebral 
conjunctiva is more often the seat of the lesion than is the bulbar portion. 
The lower lid is more often involved than the upper. The disease is gen¬ 
erally unilateral. The cornea often is the seat of superficial inflammation. 
Iritis may develop. "While the pre-auricular gland on the affected side is 
hard, swollen, and tender, it does not often suppurate. The submaxillary 
and cervical glands may be infiltrated. 

The clinical features of the disease have been grouped by Sattler as 
follows: First group—characterized by small miliary ulcers, which may 
coalesce, generally attacking the palpebral, but sometimes affecting the 
bulbar conjunctiva. Second group—characterized by grayish or yellowish 
subconjunctival nodules, varying in size, but rarely larger than a hemp- 
seed. Third group—characterized by florid, hypertrophied papillae and 
rounded outgrowths of granulation tissue, springing from the palpebral 
conjunctiva or situated in the fornices, recurring after removal, and accom¬ 
panied by edema and thickening of the lids. Fourth group—“lupus” of 
the conjunctiva, characterized by numerous pedunculated, cockscomb-like 
excrescences in the fornices, of a jelly-like consistency, often showing more 
or less ulceration. To these Eyre adds another group to cover those cases 
characterized by distinctly pedunculated tumors, microscopically resem¬ 
bling papillomata: cases without involvement of the subconjunctival tissue 
or production of any symptoms other than mechanical ones. Pain, as a 
rule, is not a prominent symptom. A moderate discharge is present. 

Etiology. —This disease is due to the tubercle bacillus, as can be 
shown by microscopic sections and by inoculation experiments. 

Diagnosis. —Tuberculosis of the conjunctiva may be mistaken for 
trachoma, papilloma, chancre, or epithelioma. Trachoma cases improve 
under treatment by silver, while tuberculosis does not. In case of doubt 
a microscopic examination of an excised portion of infiltrated tissue should 
be made. In the absence of the tubercle bacillus inoculation experiments 
should be undertaken. This method is more reliable than microscopic 


19 


290 


MODERN OPHTHALMOLOGY. 


examination, although it requires a longer period (six or eight weeks) 
before the diagnosis can be determined. 

Prognosis. —This will depend on the ability of the surgeon to remove 
all of the diseased tissue. Where this is not practicable a cure should not 
be expected, although vision may be lost by involvement of the cornea. 
Spontaneous cure of conjunctival tuberculosis is possible. 

Treatment. —Stephenson has cured one case by x-ray treatment. If 
this means fails, early and complete removal of the diseased conjunctival 
tissue and enucleation of swollen pre-auricular glands should be under¬ 
taken. This can be done with the knife, spoon, or cautery. Any tuber¬ 
culous material which is left behind may cause general infection. After 
the diseased tissue has been removed a collyrium of bichlorid of mercury, 
or a dusting-powder, such as iodoform or aristol, can be applied. The 
general system should receive proper treatment. Good food, fresh air, 



Fig. 214.—Tuberculosis of the conjunctiva. (Eyke.) 

Granulations are present on the temporal side of the bulbar conjunctiva of the right 
eye, with a central caseous mass. 

and proper climatic conditions should be secured. Tuberculin injections 
have not proved efficient in this disease. 

Argyrosis of the Conjunctiva.-—As a result of the long-continued 
application of a solution of nitrate of silver or of protargol, or from ex¬ 
posure to the action of silver-dust, the conjunctiva becomes discolored. 
Prolonged use of sulphate of iron will cause a yellow coloration of the con¬ 
junctiva (sidcrosis conjunctivse). An example of argyrosis is shown in 
Fig. 7, Plate XI. Silver is deposited in the elastic fibres of the conjunctiva 
in the form of an albuminate or an oxid. The discoloration of silver causes 
the conjunctiva to appear bluish, while the stain following protargol is of 
a dirty-brownish color. There is no remedy for this condition. 

Leprosy. — According to Neve, conjunctivitis occurs frequently in 
lepers, the anesthetic lids being exposed to the bites of flies and mosquitoes 
and to injury from foreign bodies. Leprous nodules occur in the con¬ 
junctiva by extension from the deeper tissues. They generally develop near 







DISEASES OF THE CONJUNCTIVA. 


291 


the corneal margin and grow into the sclera and cornea. The process 
extends and causes iritis, nodules appearing in the iris. 

Lupus of the Conjunctiva may appear primarily, but is generally due 
to extension from the skin of the eyelid. In the conjunctiva it appears 
as an ulcer which may heal in one direction and extend in another. The 
lupous ulcer presents a bottom covered with granulations in which the 
bacillus tuberculosis has been found. Since the same microorganism is 
present in both tuberculosis and lupus, the diagnosis must be made by 
the clinical appearances. The treatment consists in excision, destruction by 
the cautery, or the application of the x-rays. 

Hemorrhage from the Conjunctiva in rare instances becomes alarm¬ 
ing, and, in the case of infants, has caused death. It may occur in persons 
who give no history of injury or of hemophilia. It has been seen to follow 
the operation of expression in trachoma, and also occurs without known 
cause. In at least three instances fatal hemorrhage has followed the appli¬ 
cation of nitrate of silver to the eyes of the newborn (Wiener). Profuse and 
repeated hemorrhages may occur for several months and suddenly cease. 
They are probably due to the presence of minute vascular tumors. When 
caused by an ulcer the bleeding vessel can be easily controlled by the applica¬ 
tion of forceps. If produced by minute vascular tumors the source of the 
hemorrhage may not be easily found. The affection is generally due to a 
lesion in the lower lid. 

Abscess of the Conjunctiva, a localized area of suppuration in the sub¬ 
conjunctival tissue, may be due to trauma, but sometimes occurs apart 
from injury or other determinable cause. It may be situated at any part 
of the bulbar conjunctiva, but is more likely to involve the region of the 
caruncle. A suppurating Meibomian cyst opening through the palpebral 
conjunctiva is not uncommon. Pus from an orbital abscess may cause the 
conjunctiva to bulge and form a fluctuating mass. These conditions, how¬ 
ever, are not abscesses of the conjunctiva in the strict sense of the term. 
Hot applications and an early incision is the treatment to be employed. 

Actinomycosis of the Conjunctiva is a very rare condition which has 
been observed by Demicheri and Vincentiis. In the case reported by the 
former observer, a young man, suffering with subacute catarrh of the 
conjunctiva, presented on the everted upper lid, along the posterior tarsal 
margin, about fifteen yellowish-gray granules, three-tenths of a millimetre 
or more in diameter, resembling a granular or follicular eruption or the 
infarcts of Meibomian glands common in elderly persons. Microscopic 
examination of the contents of these granules showed typical masses of 
actinomycosis. The focus of infection was excised, with recovery. 

Syphilis of the Conjunctiva.—The conjunctiva is subject to the pri¬ 
mary, secondary, and tertiary lesions of syphilis: chancre, macular and 
papular syphilides, copper-colored spots, mucous patches, gummata, and 
ulcer. Chancres not only involve the conjunctiva by extension from the 
eyelids, but have also been seen primarily in the upper or lower fornix 


292 


MODERN OPHTHALMOLOGY. 


or on the bulbar conjunctiva. Chancre (Fig. 7, Plate VII) here gives 
rise to the same characteristic symptoms as elsewhere. There is a small 
swelling and induration, ulcerated at the top, absence of pain, and enlarge¬ 
ment of the lymphatic glands. The chancre feels like a piece of parchment. 
Buckley found over 4 per cent, of extragenital chancres located on the 
lids and conjunctiva. Infection occurs chiefly by the unclean finger of 
the patient or by the diseased mouth of another person. The latter source 
may be immediate, as in the removal of foreign bodies under the conjunctiva 
by the tongue; or intermediate, as by soiled towels, gloves, the wearing 
of a mask, the use of an opera-glass as in Falcone’s case, or the use of 
unclean surgical instruments. The diagnosis of chancre of the conjunctiva 
is not difficult provided the surgeon thinks of the possibility of its occur¬ 
rence, but the condition may be mistaken for gummatous ulcer, epithe¬ 
lioma, tuberculosis, or chalazion. The prognosis is favorable, only a small 
scar remaining. The local treatment includes cleanliness and the use of 
a mild mercurial ointment. 

Mucous patches, which occur rarely on the conjunctiva, look like the 
same lesion elsewhere. Under internal and local treatment they generally 
heal rapidly. Copper-colored spots are rarely seen, and grouped papular 
syphilides are also of rare occurrence and are found in connection with 
the same lesions of the face and eyelids. Gunnnata of the conjunctiva are 
rare, and, according to de Beck, usually are developed in the ridge where 
the conjunctiva passes into the cornea, but may occur in other parts of 
the mucous membrane. They form rounded tumors of the size of a split 
pea. They are smooth and firm, present a light-pink color, and when 
uncomplicated cause no pain. They grow rapidly, and quickly disappear 
under proper general and local treatment. In the absence of a specific 
history they may be mistaken for cyst, abscess, or chalazion. These cases 
should be treated with iodid of potassium internally and cleansing washes 
locally. 

Conjunctival Ulcers, aside from those occurring as a part of a tuber¬ 
cular or malignant process, are probably of more frequent occurrence than 
has been generally supposed. These lesions, which are often situated about 
one millimetre from the cornea and measure from two to four millimetres 
in diameter, may appear in any part of the membrane, but the bulbar 
conjunctiva corresponding to the interpalpebral space is a favorite site. 
The disease may cause marked injection, slight swelling, and little pain. 
Such a lesion will be overlooked easily unless a solution of fluorescin is 
used to outline it. Where only the epithelium has been cast off the stain 
does not show as well as in deeper ulcers. 

The chief causes of conjunctival ulcers are trauma and syphilis. Some 
cases follow the breaking down of abscesses due to measles, variola, and 
other exanthematous diseases. Others are the result of local necrosis, such 
as occurs in diphtheria of the conjunctiva. The condition may be mis¬ 
taken for acute catarrhal conjunctivitis. 


DISEASES OF THE CONJUNCTIVA. 


293 


Subconjunctival Ecchymosis (Subconjunctival Hemorrhage) is a com¬ 
mon condition which follows injuries or operations or may occur sponta¬ 
neously. It consists of a collection of blood beneath the ocular or transi¬ 
tional part of the conjunctiva. It can be distinguished from inflammation 
by its uniformity in color and by the absence of vessels. Subconjunctival 
hemorrhage is frequent after fractures of the skull. It is common in 
elderly people whose arteries are atheromatous, and often occurs in children 
with pertussis. The condition does not call for any particular treatment. 
The blood will be absorbed in from ten to twelve days. 

Emphysema of the Conjunctiva occurs from the same causes that 
produce a similar condition of the lids, viz.: fracture of the nasal bones 
or of the walls of the frontal or ethmoidal cells, or ulceration of the bones 
leading to perforation of these spaces. It may result from forcible blowing 
of the nose. The swelling caused by emphysema is tense, elastic, and 
crepitates on pressure. It may accompany ecchymosis or may exist alone. 
The proper treatment is the application of a compress bandage. 

Chemosis is a condition in which the ocular portion of the conjunctiva 
becomes edematous and is lifted up around the cornea, the swelling being 
often so great that the membrane projects between the eyelids. Such swell¬ 
ings may be classified as active, or inflammatory, and passive, or non¬ 
inflammatory. The former is present in almost all cases of purulent con¬ 
junctivitis. It follows the bites of insects and the stings of bees. It is 
occasionally seen in acute catarrhal conjunctivitis. It is of common occur¬ 
rence in acute glaucoma, iritis, iridocyclitis, and in infection following 
operations on the globe. It is also present as a symptom of nephritis, and 
is sometimes caused by the internal use of certain drugs, such as iodid of 
potassium and quinin. The passive form of chemosis is seen in old alco¬ 
holics and in gouty persons. 

A form of edema known as filtration chemosis occurs when the aqueous 
humor escapes beneath the conjunctiva through a fistula at the corneo¬ 
scleral margin. 

The pathologic condition in chemosis is simply an infiltration of the 
subconjunctival tissue with leucocytes, transuded blood, and fibrin. There 
is also a formation of new vessels. The condition disappears with the 
subsidence of the cause, and does not call for treatment except when the 
swelling threatens the integrity of the cornea. In this event the swollen 
tissue may be incised in numerous places with a cataract-knife. The small 
cuts are to be made radial to the cornea. 

Symblepharon, an abnormal adhesion of the eyelid to the globe (Fig. 4, 
Flate VII), results from the union of two raw surfaces, and may be caused 
bv trauma, such as cuts or burns, or may result from pemphigus or diphthe¬ 
ritic or purulent conjunctivitis. It is rarely seen as a congenital condition. 
The attachment is generally between the lower lid and the globe. It may 
consist of a few slender threads of thickened conjunctiva or may exist as a 
dense band of tissue. Anterior symblepharon is an adhesion forming a bridge 


294 


MODERN OPHTHALMOLOGY. 


between the lid and globe, but not reaching to the fornix; in the posterior 
variety the band involves the fornix. As a result of symblepharon there is 
limitation of ocular movements, and thus diplopia may be produced. When 
the adhesions involve the centre of the cornea vision will be reduced. 
Symblepharonic eyes are often irritated and hyperemic from constant trac¬ 
tion. In some cases the lids are fastened to the globe in such a way that 
closure is impossible, and thus lagophthalmos is caused, with resulting 
corneal mischief. Often there is also entropion and trichiasis. Mild cases 
of symblepharon give rise to few or no symptoms. 

The term symblepharon has been applied also to the contraction and 
shrinking of the conjunctiva following trachoma. Here there is no adhe¬ 
sion of opposing surfaces, but a slow diminution in size of the cul-de-sac. 

The prognosis of symblepharon depends on the extent to which adhe¬ 
sions have taken place. In anterior symblepharon the prognosis is favor¬ 
able; in the posterior form it is grave, and in total symblepharon little 
improvement is to be expected. When caused by shrinking, the condition 
is incurable. The treatment is surgical. Various operations for its relief 
are described in the latter part of this chapter. 


INJURIES TO THE CONJUNCTIVA. 

It is necessary to consider the lodgment of foreign bodies and the 
effect of trauma and of chemicals. 

Foreign Bodies often lodge upon the conjunctiva, and are of the most 
varied nature. They cause pain, photophobia, lacrimation, and blepharo¬ 
spasm. When in the lower cul-de-sac they are easily observed. If in the 
upper fornix they are often overlooked, and can be seen best when secondary 
eversion of the lid is performed or when the lid is lifted away from the 
globe while the patient looks downward. The foreign body may rest on 
the conjunctiva or become fastened in the membrane, either by the force 
which originally propelled it or by the action of the patient in rubbing his 
eye. A foreign body may be washed away by the tears. If found loose in 
the conjunctival sac, it can be removed by flushing the eye with warm physio¬ 
logic salt solution. If attached, it can often be removed by wiping the 
conjunctiva with a toothpick wrapped in absorbent cotton. The foreign 
body becomes caught in the cotton, and thus is not lost. When deeply 
lodged in the upper fornix foreign substances may remain in situ for many 
months, producing much or little discomfort, and leading to a luxuriant 
growth of granulations. Insects, bugs, and larvas may lodge in the cul- 
de-sac and often cause intense irritation, owing to the action of the formic 
acid which most of them contain. In all cases where the presence of a 
foreign body is suspected, the search for it should not be abandoned until 
after the upper fornix has been explored. 

Burns of the Conjunctiva (Fig. 1, Plate X) are frequently caused by 
lime, pieces of hot metal, or gunpowder. Scalds often follow the bursting of 


DISEASES OF THE CONJUNCTIVA. 


295 


water-gauges on locomotives. The gravity of such injuries is often unap¬ 
preciated at the time of the receipt of the injury. Among the results are 
ankyloblepharon, symblepharon, entropion, ectropion, as well as lesions of 
the cornea and destruction of the lids. The raw conjunctival surfaces grow 
together and lead to extensive adhesions. In the treatment an attempt 
should be made to prevent the union of raw surfaces. If the lower cul- 
de-sac has been deeply burned, adhesion will he sure to occur and the fornix 
will be obliterated. Burns of the upper cul-de-sac without destruction of 
the eyelid are rarely seen. 

The treatment of burns of the conjunctiva should be begun at the 
earliest possible moment. Acids can be neutralized by a 1-per-cent, strength 
solution of sodium bicarbonate or potassium bicarbonate (saleratus). Hot 
metal should be removed as soon as possible. In such injuries the injection 
of castor-oil into the cul-de-sac is often advised. In burns by lime the 
offending substance should be removed as early as possible, and to accom¬ 
plish this a jet of cold water is to be employed. The use of water in such 
cases has long been denounced by ophthalmic writers, but recently Andreae 
has shown that cold water neutralizes the heat generated by the contact 
of lime with tears, and aids in the speedy removal of the lime. Contrary 
to popular belief, water in contact with oxid of calcium does not generate 
sufficient heat to injure the eye within ten minutes. It may happen that 
the pieces of lime can be removed more rapidly by the use of a spatula, 
knife-blade, or spud. After removal has been accomplished holocain can 
be used to relieve pain and iced compresses can be applied to control in¬ 
flammatory action. The adhesion of raw surfaces must be prevented by 
passing a probe into the forniees twice daily. A^aselin can be used within 
the cul-de-sac. If these measures are insufficient, Coover and Black advise 
the use of egg-film placed between the raw surfaces. The film, taken from 
the small end of an egg is to be placed over the globe and changed daily. 
In case the cornea is involved the use of atropin will be in order. 

In injuries by gunpowder the eye should be anesthetized by holocain 
or cocain and the powder-grains should be picked out by means of a cataract- 
needle or snipped off with scissors. In the after-treatment the daily use of a 
solution of boric acid will be in order. In such cases the cornea often is 
involved and atropin must be used. Often the powder-grains will be driven 
through the cornea and into the iris or lens. 

Trauma of the conjunctiva, aside from the lodgment of foreign bodies 
or burns, must be considered. The membrane may be torn by blows from 
the fist, the rent being often situated in the bulbar conjunctiva concentric 
with the cornea. Such cases require cleanliness, a suture, and cool appli¬ 
cations. 

AFFECTIONS OF THE CARUNCLE. 

The Plica Semilunaris and Caruncle participate in inflammations of 
the conjunctiva. These parts are frequently red and swollen in persons 


29G 


MODERN OPHTHALMOLOGY. 


suffering from eyestrain, and particularly in those with imperfect conver¬ 
gence. The older writers gave considerable attention to a localized inflamma¬ 
tion of the caruncle which they named encanthis. It is attended by infection 
and swelling of the sebaceous glands, and may lead to suppuration, in which 
case the small abscess should be opened. 

Excessive development of hairs on the caruncle, trickosis carunculce , 
may cause persistent hyperemia, with the sensation of a foreign body. 
Epilation or excision of the hair-bulb is the proper treatment. 

Tumors of the Caruncle. — As primary growths, adenomata, papil¬ 
lomata, cylindromata, fibromata, lymphangiomata, sarcomata, and carcino¬ 
mata have been seen in this region. They should be excised. Congenital 
telangiectasia? and dermoid cysts have also been observed. Lithiasis of the 
caruncle is a rare affection. The concretions should be picked out with a 
cataract-needle. 



Fig. 215.—Eye-speculum. (Author.) 


OPERATIONS ON THE CONJUNCTIVA. 

The chief operations performed on the conjunctiva are those for pteryg¬ 
ium, symblepharon, trachoma, and tumors. Such minor procedures as the 
removal of a foreign body from or the opening of an abscess of the con¬ 
junctiva, or the application of medicines to this membrane need no further 
mention in this place. In all operative procedures limited to or involving 
the conjunctiva it will be necessary to follow certain rules regarding the 
preparation of the field of operation. The necessity is none the less patent 
although the impossibility of rendering the conjunctiva sterile is now 
recognized. The skin of the face, forehead, and eyelids must be washed 
with hot water and soap, then with bichlorid solution (1 to 5000). In 
case pus or muco-pus is present in the lacrimal sac the secretion must be 
removed and the passages flushed with the same solution. The conjunctiva 
is to be cleansed by causing warm sterile water to flow over its entire sur¬ 
face, the upper lid being everted. This is followed by a flushing with 
bichlorid (1 to 5000). The eye is then to be covered with a sterile towel 
wrung out of the same solution. The conjunctiva is then anesthetized with 



DISEASES OF THE CONJUNCTIVA. 


297 


a sterile holocain or cocain solution, the medicine being conveyed by a sterile 
dropper. 

Pterygium Operations.—A pterygium may be treated by (1) excision, 
(2) transplantation, or (3) cauterization. The instruments needed are a 
stop-speculum, fixation forceps, dissecting forceps, sharp-pointed scissors, 
strabismus-book, needles, needle-holder, sutures, a cataract-knife, and an 
electrocautery. 

1. The Excision Operation is begun by seizing the pterygium near 
the corneoscleral margin and lifting the growth up. The apex can then be 
shaved off from the cornea. If the surgeon prefers divulsion a small cut 
is made beneath the neck of the growth with sharp-pointed scissors and a 
strabismus-hook is passed beneath. The divulsion is accomplished by tear¬ 
ing in the direction of the cornea. It is claimed that this procedure gives 
a better separation between the pterygium and the cornea than can be 
obtained otherwise. The apex being freed, the body of the growth can 
be separated from the normal conjunctiva back as far as the caruncle, and 
then excised. The gap is filled by uniting the adjacent conjunctiva with 
interrupted sutures. This operation is applicable only to small pterygia. 
In large, fleshy ones, particularly in those with expanded bases, total excision 
is not advisable, since the motion of the eye in the opposite direction may 
be limited b} r the cicatrix. In such cases it will be best to excise only the 
apex and a part of the body of the growth or to resort to transplantation. 
Complete excision of the pterygium, the denuded area being covered with 
a Thiersch flap, has been successfully practiced by Hotz. 

2. Transplantation is done by first separating the apex as described 
above. The growth is then to be split in the direction of the long axis, 
one half being transplanted into the upper, the other into the lower, fornix. 
The raw space made by the separation of the growth from the eyeball is 
filled by suturing the adjacent conjunctiva. To facilitate sliding of the 
membrane, incisions are to be made concentric with the cornea. A gauze 
dressing is to be applied and the sutures are removed on the fourth day. 
There are several modifications of the transplantation operation, that of 
McEeynolds being preferred by the author. The apex of the growth is lifted 
up from the cornea and is separated from it by shaving it off with a von 
Graefe knife. Then the pterygium is to be thoroughly lifted from the 
underlying sclera for a distance of five millimetres from the cornea. An 
incision is made along the lower border of the growth for a distance of ten 
to twelve millimetres. The ocular conjunctiva is separated from the globe 
below the growth, the separation extending to the lower fornix. The apex 
of the pterygium is to be flattened and unrolled with forceps, while two 
needles are passed through the apex of the growth and are brought out 
deeply in the fornix, as is shown in Fig. 216. On tying the suture the 
pterygium is buried and at the same time the denuded scleral area is 
covered with conjunctiva. The suture is removed at the end of a week. 

3. Cauterization. —This (Coe’s) method, according to Loring, is a 


298 


MODERN OPHTHALMOLOGY. 


valuable procedure. It consists simply in the application of the cautery to 
the apex of the pterygium on the cornea, the body of the growth not being 
touched. The operation is said not to be followed by pain or inflammatory 
symptoms. One thorough application is said to be sufficient. 

Symblepharon Operations.—Procedures for the relief of symblepharon 
anterius are successful, while operations for symblepharon posterius fre¬ 
quently are failures. In the former condition the adhesion is severed close 
to the eyeball, and reunion is prevented by daily use of the probe. In case 



Fig. 216. —Operation for pterygium. (McReynolds.) 

the symblepharon extends from the cornea back to the fornix, the ingenuity 
of the surgeon will be taxed. Among the best operations for this condition 
are the procedures of Knapp, Arlt, Teale, and Harlan. 

In Knapp’s method, after adhesions have been severed, the defect is 
covered with vertical, stretched flaps of conjunctiva, which are stitched into 
the fornix. In Arlt’s operation the corneal part of the symblepharon is 
detached and is stitched into the fornix by threads passed through the lid r 
while the denuded surface is covered by sliding the conjunctiva from each 



Fig. 217. —Operation for symblepharon. (Teale.) 

A, Tip of the symblepharon. B, C, Conjunctival flaps. 1), Denuded surface left by removal 

of the symblepharon from the eyeball. 


side. This method of disposing of symblepharon insures a conjunctival 
surface opposed to the raw spaces if the conjunctiva cannot be stretched 
sufficiently to cover the defect. If such a contingency arises it will be best 
to cover the raw surface with a bit of mucous membrane from the patient’s 
mouth, or a piece of rabbit’s conjunctiva, or a skin-graft after the manner 
of Thiersch. 

In Teale’s operation the tip of the symblepharon is left in situ and 
the remainder is dissected from the eyeball down to the fornix. The defect 
is closed by conjunctival flaps, as shown in Fig. 217. 





DISEASES OF THE CONJUNCTIVA. 


299 


Harlans operation (Fig. 218), which the author has used successfully 
in total symblepharon of the lower lid, is performed in this manner: The 
eyelid is separated from the globe and a bridge is made of the lid by an 
incision (A-B) parallel to its margin. An incision (C-D) serves to 
loosen a skin-flap, which is turned inside out, drawn beneath the bridge, 
and stitched by its raw surface to the raw surface of the lid. The space 
lelt by the turning of the flap can be closed by sutures, an incision (C-E) 
being made to relieve tension on the tissues. 

Skin-grafting in Symblepharon.—Total symblepharon of one eyelid, 
a condition formerly supposed to be incurable, has recently furnished a 
more favorable prognosis, cases having been operated upon successfully by 
May, Hotz, and others. Formerly mechanical devices were used to prevent 
reunion of the cicatricial bands, but of late surgeons have learned that no 
permanent good result can be secured unless the raw surfaces are covered 
with epithelium. Mechanical devices (shields of glass, porcelain, lead, and 
silver) are now used to hold large Thiersch grafts in position until they 
have become united to the underlying tissue. 




Fig. 218.—Operation for symblepharon. (Harlan.) 


Removal of the Tarsus and Retrotarsal Folds.—This (Heisrath’s) 
operation dates from 1882, and in recent years has come into use in 
the treatment of trachoma, owing to KuhnFs enthusiastic advocacy of it. 
The operation is begun by everting the upper lid, which is seized by two 
fixation forceps and drawn strongly upward. This exposes the junction 
of the ocular and palpebral conjunctiva, along which line a curved hori¬ 
zontal incision is made through the conjunctiva only, from canthus to can- 
thus. Three stitches are now passed through the bulbar conjunctiva; the 
fixation forceps is now released, and the lid is held everted over a spatula 
while an incision is made parallel with and from three to five millimetres 
from the ciliary border. The conjunctiva and tarsal plate are then dis¬ 
sected carefully from the orbicularis muscle. The wound is irrigated with 
bichlorid solution and closed by the sutures already passed through the bul¬ 
bar conjunctiva. To obtain a satisfactory result the sutures must be passed 
through corresponding points in the wound-margins. 

Excision of the Upper Cul-de-sac, an operation for the cure of trachoma 
which was reintroduced by Galezowski in 1874, did not become popular 






300 


MODERN OPHTHALMOLOGY. 


until after the publications of Brachet (1882) and Despagnet (188-1). 
Ilotz, Jaesche, and Lloret condemned the operation. Lately it has come 
into use largely by reason of the opinion of Stephenson, who performed 
excision of the upper fornix on more than seventy eyes, and saw only one 
untoward result, his cases having been under observation for periods vary¬ 
ing from two to six years. After a successful excision a transverse line of 
scar-tissue marks the site of operation, the fornix being represented by a 
shallow depression. The ocular movements are not limited and ptosis is 
not usually induced. The upper fornix is removed, because it is the seat 
of the tissue in which the trachomatous process is most marked and least 
amenable to topical treatment. Bemoval of this tissue lessens the danger of 
recurrence of the trachomatous process and of pannus. 



Fig. 219.-—Excision of the upper cul-de-sac. (After Stephenson.) 

The operation is done under local anesthesia. The upper lid being 
everted, the fornix is seized and drawn downward. At each extremity of 
it a needle is passed bearing a silk suture, whose ends are held taut by an 
assistant. With scissors the conjunctiva is separated from its attachment 
to the tarsal plate. The subconjunctival tissue is then dissected and the 
operation is completed by cutting through the posterior layer of the cul- 
de-sac. Free bleeding during the operation may necessitate torsion of a few 
vessels. Sutures are not used to close the wound. The reaction is usually 
slight. If large granulations appear in the wound during healing, they can 
be cut off with scissors. Ptosis may follow the operation and soon disappear. 

Expression of the Contents of Trachoma Follicles, an old method of 
treatment, has been popularized by the articles of Hotz, ISToj'es, and Knapp. 
The procedure requires two pairs of roller forceps, the instrument of Knapp 











DISEASES OF THE CONJUNCTIVA. 


’ 301 


being one of the best. Under cocain or general anesthesia the upper lid is 
everted and seized with the forceps, one pair being used to steady the lid 
while the other is employed to roll out the trachomatous material. Care 
should be taken to reach all parts of the fornices. After the squeezing 
process is finished cold applications are used for two or three days, followed 
by appropriate local treatment. 

Grattage of the Conjunctiva. —This operation, which many French 
ophthalmologists recommend for trachoma, requires a pair of fixation 
forceps, a tliree-bladed scarifier, a tooth-brush, and a solution (1 to 500) 
of bichlorid of mercury. The everted lid being held by forceps, the sur¬ 
geon thoroughly scarifies the conjunctiva and scrubs the incised surface 
with a stiff brush soaked in the bichlorid solution. Cold applications are to 
be used for a few days. A probe is used daily to prevent the formation of 
adhesio.ns between the palpebral and ocular parts of the conjunctiva. 

Periectomy. —As the first step in this operation, which is done for 
pannus, a piece of bulbar conjunctiva two or three millimetres wide is 
removed close to the peripheral border of the pannus. Then a correspond¬ 
ing strip of subconjunctival tissue is excised. The underlying sclerotic, 
which Boeckmann claims is always the seat of scleritis in these cases, is 
scarified with a cataract-knife until it appears off a normal whitish color 
and the vascularization of the cornea disappears. This step is usually fol¬ 
lowed by a copious arterial hemorrhage. The last step is to arrest this 
hemorrhage and provide for an open, broad wound. If the conjunctiva is 
permitted to cover the scleral wound, the object of the operation will be 
defeated, the aim being to form a scar which shall be a bar between the 
corneal and pericorneal inflammation. To prevent the conjunctiva be¬ 
coming attached, the eye is turned in the opposite direction and the wound 
is filled with powdered iodoform, while hemorrhage is controlled by pressure 
with sterile gauze, the pressure being continued for half an hour. The 
operation is followed by increased vascularization of the cornea; but this 
gradually disappears, and in three or four weeks the condition of the cornea 
is much improved. 

Peritomy (Syndectomy; Tonsure of the Cornea). —A less formidable 
and also less efficient operation than periectomy is peritomy. Under local 
anesthesia a strip of conjunctiva is removed from around the limbus. Blunt 
scissors are used to cut the membrane. A strip three to four millimetres 
wide is removed adjacent to the cornea. A small Volkmann scoop is then 
used to remove the subconjunctival tissue. A gauze dressing is applied, 
and healing is uneventful. This operation was formerly much in vogue in 
the treatment of pannus. 

Subconjunctival Injections. —After cleansing the conjunctival sac a 
local anesthetic is used and the lids are held apart by the fingers of an 
assistant or preferably separated by a speculum. Then with forceps the 
conjunctiva is lifted up at a point six to eight millimetres from the limbus 
and the needle of a hypodermic or Pravaz syringe, filled with the fluid, is 


302 


MODERN OPHTHALMOLOGY. 


passed to the depth of two or three millimetres in a direction parallel with 
the sclera. The fluid is then discharged, 2 to 10 minims being injected. 
The process may be repeated at intervals of two or three days. 

Indications. —Subconjunctival injections are valuable in the treat¬ 
ment of inflammations of the iris and ciliary body, in sloughing ulcers of 
the cornea, in scleritis and episcleritis, and in detachment of the retina. 
They are of little, if any, value in chronic keratitis, in chorioiditis, in 
retinitis, and in optic neuritis. The subconjunctival injection of cocain 
is used in patients requiring enucleation or evisceration who cannot or will 
not take a general anesthetic. 

Solutions Used. —Bichlorid and cyanuret of mercury, trichlorid of 
iodin, sodium chlorid, and lietol (cinnamate of soda) are the substances 
which are most frequently used at the present day. Many others have been 
tried and abandoned. As regards strength, bichlorid is used from 1-30,000 
to 1-1000; trichlorid of iodin, 1-2000 to 1-500; sodium chlorid, 0.75-1000 
to 2, 5, 10, or 20 per cent.; lietol, 1 per cent. 

Accidents. —In spite of the use of a local anesthetic, severe or ex¬ 
cruciating pain not infrequently follows subconjunctival injections. Ac¬ 
cording to Darier, the addition of a few drops of a 1-per-cent, strength 
solution of acoin to the medicament to be used subconjunctivally will render 
the injection painless. Subconjunctival ecchymosis may follow the injury 
to a vessel. Injury to the sclera will not occur if reasonable care is used. 
Localized necrosis of the conjunctiva may occur after a subconjunctival 
injection of a bichlorid solution. 


CHAPTER VIII. 


DISEASES OF THE CORNEA. 

Since the cornea is the most exposed part of the eyeball, it is par¬ 
ticularly liable to injury. Devoid of blood-vessels, except at the extreme 
periphery, it readily becomes necrotic under the influence of pathologic 
processes. Hence it is not surprising to find that corneal diseases form 
a large percentage (25 to 33) of ophthalmic affections, and that of 10,000 
blind persons Dhthoff found that over 13 per cent, had lost their sight by 
corneal diseases. If to these are added the cases in which purulent con¬ 
junctivitis produced corneal complications, the percentage of blindness from 
corneal disease is more than 27. Hence the great importance of corneal 
injuries and diseases to the patient, to the general practitioner of medicine, 
and to the ophthalmic surgeon. Although the layers of Bowman and Des- 
cemet possess great resisting power, all parts of the cornea are susceptible to 
pathologic influences. Unfortunately for ophthalmic writers, the making 
of a rational division of corneal diseases is as yet impossible, since there 
is no way of approaching these affections according to a fixed basis: i.e., 
one that is etiologic or anatomic. 


CONGENITAL ANOMALIES. 

Opacities often occur in connection with anomalies of size and form 
of the cornea. In some instances corneal clouds are the only demonstrable 
changes. Such opacities may be stationary or progressive after birth, or 
may disappear entirely. Whether these opacities are due to an arrest of 
development or to an intra-uterine inflammation is a question which is 
still under dispute,• although most of the late authors incline to the latter 
view. The form of the opacity presents many variations: sometimes there 
is a circular cloud involving the whole of the limbus (embryotoxon) ; or 
several sickle-shaped opacities are found; or tongue-shaped opacities occupy 
the periphery of the cornea, resembling the residuum of the so-called 
sclerosing keratitis of extra-uterine life; or a diffuse, grayish-white, dense 
opacity, looking like porcelain, involves either the whole cornea or the 
central portion. In many of the cases last mentioned alterations in shape 
(keratoconus or keratoglobus) are present; or there is an increase of intra¬ 
ocular tension leading to hydrophthalmos. Such dense opacities arise from 
the posterior surface of the cornea. If only a simple cloud is present, the 
lesion is in the endothelium. In enlargement and ectasia of the cornea 
the existence of an ulcer of the posterior surface is to be assumed (von 
Hippel). 


(303) 


304 


MODERN OPHTHALMOLOGY. 


Pigmentation.—Kayser saw a patient with congenital green coloration 
of the periphery of the cornea. 

Congenital Ectasia is a rare malformation which Pincus attributes 
to inflammation occurring in the second half of fetal life. It is probably 
due to an arrest of development in the fetal cleft, forming a coloboma of the 
cornea, which in the later weeks of intra-uterine life becomes filled with clear 
corneal tissue. In Wiirdemann’s case (Fig. 220) a small “segment was 
implanted on the cornea like a little oval watch-crystal, five millimetres high 
and seven millimetres in width, perfectly clear and of higher refraction, so 
that the subjacent portion of the iris appeared magnified.” This condition 
has been misnamed congenital staphyloma. The term staphyloma is applied 
only to those cases in which involvement of the iris coexists with protrusion 
of the cornea. 

Hydrophthalmos will receive consideration in the chapter on “Glaucoma.” 



Fig. 220 —Congenital ectasia of the cornea. (Wurdemann.) 
1 , Front view. 2 , Lateral view. 


Megalocornea and Keratoglobus are terms used synonymously to indi¬ 
cate enlargement of the cornea. The difference between them and hydroph¬ 
thalmos should be clearly understood. In megalocornea the eye shows no 
signs of internal disorganization. There is no excavation of the optic nerve, 
and good vision may be present. In hydrophthalmos there is excavation 
of the nerve-head, internal disorganization of the eye, and loss of vision. 

Megalophthalmos is a rare congenital condition in which the eye is 
enlarged in all its diameters and pathologic changes are absent. 

The congenital conditions here mentioned, with the possible exception 
of hydrophthalmos, do not admit of treatment. 

TUMORS OF THE CORNEA. 

Primary tumors of the cornea are extremely rare, most of the growths 
involving this structure having their origin in the conjunctiva. Among 
the primary corneal growths which have been reported by competent ob¬ 
servers are papillomata, fibromata, myxomata, sarcomata, epitheliomata, 
dermoids, and keloids. Snellen, Galezowski, Stellwag, Colsmann, Lagrange, 




DISEASES OF THE CORNEA. 


305 


and Treacher Collins have met with epitheliomata of the cornea. Rum- 
schewitz, Panas, and Pagenstecher have reported cases of primary sarcoma 
of the cornea. Silex saw a fibroma. The author has observed one case of 
symmetrically placed tumors of the corneas, which histologic examination 
showed to be fibromata. Westcott met with a keloid of the cornea occurring 
in a babe with staphyloma. Similar cases have been reported by R. Simon 
and I. Szokalski. Corneal cysts also occur. They are usually implantation 
cysts and follow perforating injuries. Collins met with one situated partly 
in the cornea, partly in the sclera, which measured 9.5 by 5 millimetres 
and was lined with laminated epithelium. Generally corneal cysts are too 
small to be seen macroscopically, and are found on microscopic examination 
of enucleated eyes. Schieek has observed the formation of four superficial 
corneal cysts in a case of blennorrhea with great chemosis. He believes that 
a superficial marginal keratitis was followed by the formation of pseudo¬ 
pterygia, beneath which the cysts developed. 

Treatment.—Since they principally occur in eyes demanding enuclea¬ 
tion, the treatment of corneal tumors is practically nil. If the growth 
is observed in an early stage, it should be removed and subjected to 
microscopic examination. The prognosis will depend upon the laboratory 
findings. 


INFLAniTATION OF THE CORNEA. 

Inflammation of the cornea (keratitis, corneitis) may be acute or 
chronic, idiopathic or traumatic, congenital or acquired, primary or sec¬ 
ondary. It may or may not end in ulceration. Keratitis may be simply 
a local process leading to abscess and ulcer; or the local manifestation of 
a constitutional disease, as the parenchymatous keratitis of inherited syph¬ 
ilis ; or it may be only a part of a disease—such as kerato-iritis and sclero- 
keratitis—involving deeper portions of the eye. In keratitis the cardinal 
signs of inflammation—-heat, swelling, redness, pain, and loss of function— 
are all absent early in the disease. The existence of keratitis is then evi¬ 
denced only by cloudiness. This lack of transparency is due to infiltration 
by leucocytes which have passed into the cornea from the adjacent blood¬ 
vessels or have originated from the fixed corneal cells by karyokinesis. 
Cloudiness of the cornea impairs vision, and often it is this which causes the 
patient to consult the surgeon. In cases of keratitis which go on to ulcera¬ 
tion, pain, photophobia, circumcorneal redness, and hyperemia of the con¬ 
junctival vessels are marked symptoms. The existence of a corneal infiltrate 
is shown by the presence of cloudiness and a lack of lustre at the affected 
spot, but the surface is not changed in curvature: i.e., it is not uneven. 
The infiltrate, in favorable cases, disappears by resorption; in unfavorable 
ones it ends in suppuration, in which case suppuration may be limited to 
the internal layers (corneal abscess) or may destroy the corneal tissue 
external to the abscess and thus leave a corneal ulcer. This ulcer is de¬ 
scribed as “foul” when its walls are still infiltrated, or “clean” when the 


20 


306 


MODERN OPHTHALMOLOGY. 


surrounding cloudiness has disappeared and its base is transparent. An 
ulcer which is covered by epithelium reflects light: i.e., is clear and bright. 
The chief clinical sign of a corneal ulcer is unevenness of the corneal sur¬ 
face, which shows an excavation. Corneal suppuration means a loss of 
substance, and this loss is repaired by a new-tissue formation which is not 
corneal, but connective tissue, and hence is opaque. Hence, a corneal opacity 
means a corneal scar. 

The source of pus in suppurative keratitis was for many years a sub¬ 
ject for controversy. It was formerly erroneously believed that corneal 
corpuscles could proliferate to form pus-cells. While “the corneal corpus¬ 
cles about an ulcer may proliferate to some extent before becoming necrotic, 
the new cells thus produced are but few as compared with the immigrated 
leucocytes” (Holden). 

In its normal state the cornea is devoid of vessels except at its extreme 
periphery, but under pathologic conditions vessels are rapidly developed, 
being necessary to the reparative process. After this is complete the 
vessels diminish in size and number and may entirely disappear. It 
is important to know the situation of vessels in the cornea, since this fur¬ 
nishes an index of the kind of keratitis present. Superficial vessels are 
clearly seen. They spring from the marginal loops of vessels in the limbus, 
and can be traced from the cornea to the limbus and thence to the conjunc¬ 
tiva. They branch arborescently. Pannus may be taken as a type of super¬ 
ficial vascularization. Here the vessels, for the most part, do not lie in 
the cornea, but in a newly formed tissue resting on the cornea. Deeply 
seated vessels are not clearly recognizable, since they are clouded by in¬ 
filtrate in the superficial corneal layers resting over them. They are of a 
reddish-gray color and arise from the vessels of the sclera close to the 
margin of the cornea. They seem to end suddenly at the corneal margin; 
and in branching they form ramifications running parallel with one an¬ 
other, like the straws of a broom. Parenchymatous keratitis shows this 
type of vascularization. 

The cornea having to sustain the intra-ocular tension, it follows that 
any pathologic process which softens this membrane renders it liable to 
the danger of alteration in its curvature. Thus, keratitis is often followed 
by staphyloma. Neighboring tissues participate in the pathologic process 
in keratitis; thus, there is conjunctival and ciliary hyperemia. Iritis and 
iridocyclitis are common in severe cases, and pus forms in the anterior 
chamber (hypopyon). While a small hypopyon may undergo resorption, 
a large one is likely to cause corneal necrosis and loss of vision. 

The origin of hypopyon has been the subject of much controversy. 
Ewing states that it has been attributed to the direct passage of leucocytes 
through Descemet’s membrane (Horner, Bokowa) ; to the traveling of 
leucocytes around Descemet’s membrane and their passage into the anterior 
chamber via the ligamentum pectinatum (Schweigger) ; to leucocytes orig¬ 
inating in the endothelium (Hoffman) ; to direct rupture of Descemet’s 


DISEASES OF TIIE CORNEA. 


307 


membrane (Weber, Verclese, Silvestri) ; to leucocytes from the canal of 
Schlemm and small, deep, circumcorneal vessels (Fuel) ; and to exudation 
from the iris (Arlt). Uhthoff and Axenfeld, after a series of careful 
investigations, doubt the origin of hypopyon from the cornea, and at¬ 
tribute it to the iris and ciliary body. Their conclusions have been gen¬ 
erally accepted by modern ophthalmologists; but old pathologic ideas die 
hard, and some surgeons still believe that hypopyon originates from a direct 
break in Descemet’s membrane and in an exudate from the iris. Elsclmig 
has attributed the breaks in Descemet’s membrane to erosions produced 
by chemotactic changes in aggregations of leucocytes on the posterior sur¬ 
face of the cornea, the leucocytes being derived from the iris, ciliary body, 
and ligamentum pectinatum. Two points in favor of this view are the 
absence of bacteria in hypopyon and its frequent occurrence with intact 
membrane of Descemet. 

Onyx, a term much used by the older writers to describe the shape 
of an hypopyon, is now applied to a collection of leucocytes in the corneal 
stroma or beneath Descemet’s membrane. It occurs chiefly in the lower 
part of the cornea. Frequently hypopyon and onyx are both simultaneously 
present in the same eye. Onyx does not move when the patient changes his 
position, while hypopyon, if liquid, does change its position. Yet it often 
occurs that hypopyon is thick, gelatinous, and immovable. In some cases 
the differentiation between these conditions can be made by oblique illumi¬ 
nation. 


CLASSIFICATION OF CORNEAL INFLAMMATIONS. 


Although no absolutely correct classification of corneal inflammations 
is possible in the present state of science, for teaching purposes it is ad¬ 
visable to set before the reader a subdivision of these diseases. Since a 
classification founded on etiologic factors is impossible, these inflamma¬ 
tions may be divided according to their location (as superficial and deep), 
or according as the process of infiltration undergoes resorption or advances 
to suppuration (non-suppurative and suppurative keratitis). For practical 
purposes the latter method is preferred, and the subjoined classification 
is submitted with the understanding that it is open to criticism:— 


(A) Suppurative Keratitis. 


1. Ulcer of the cornea. 

2. Creeping ulcer of the cornea. 


3. Neuroparalytic keratitis. 

4. Lagophthalmic keratitis. 


5. Xerophthalmic keratomalacia. 
(B) Non-suppurative Keratitis. 


1. Phlyctenular or eczematous keratitis. 

2. Interstitial keratitis. 

3. Vascular keratitis. 

4. Bullous and vesicular keratitis. 

5. Aspergillar keratitis. 

0. Malarial keratitis. 

7. Filamentary keratitis. 


8. Keratitis punctata. 

9. Superficial punctate keratitis. 

10. Ribbon-shaped corneal opacity. 

11. Herpes of the cornea. 

12. Marginal keratitis. 

13. Striped keratitis. 

14. Disc-like keratitis. 


15. Grill-like keratitis. 


308 


MODERN OPHTHALMOLOGY. 


(A) SUPPURATIVE KERATITIS. 

Ulcer of the Cornea.—When a corneal infiltrate does not undergo 
resorption it ends in suppurative keratitis. It must be understood, how¬ 
ever, that non-suppurative and suppurative inflammations merge into one 
another by insensible degrees. If the suppuration leads to a circumscribed 
collection of pus between the corneal lamellae, the condition is known as 
corneal abscess. If, in this condition, the superficial corneal layers undergo 
necrosis, so that the abscess communicates with the external world, the case 
is one of corneal ulcer. In the life of an ulcer several stages are recognized. 
When the ulcer is spreading and its edges are “foul,” we speak of the state 
of progression; when it begins to become “clean” and shows signs of healing, 
the stage is that of regression; and, when it undergoes healing, we speak 
of the stage of cicatrization. This last stage invariably leaves a scar of 
greater or less extent, and this interferes with the transparency of the 
cornea. If the process of ulceration is unchecked, it leads to perforation 
of the cornea, with such important sequelas as iris-prolapse, the formation 
of anterior synechise, or anterior polar cataract, and in some instances 
destruction of the eye by panophthalmitis. Microorganisms are necessary 
to corneal suppuration, and these are generally introduced from without, 
finding lodgment in some minute spot of corneal tissue from which the 
epithelium has been exfoliated or removed by trauma. The warmth and 
moisture found about the eye are factors favorable to the growth of bac¬ 
teria. Corneal wounds which are promptly treated and dressed aseptically 
rarely lead to suppuration. Unfortunately there are no means of rendering 
the eye absolutely aseptic, compatible with the integrity of its tissues. 

Perforation occurring in the course of an ulceration of the cornea is 
a result of several factors, such as increased intra-ocular pressure from 
sneezing or crying, from blepharospasm, or from increased blood-pressure. 
A sharp pain and a. sudden escape of aqueous humor are the subjective signs 
of perforation. Objectively it is indicated by minus tension of the eye, 
obliteration of the anterior chamber, with or without the presence of iris- 
prolapse. Previous to the occurrence of perforation, when the ulcer has 
acquired great depth, there may be a projection of the membrane of Des- 
cemet, in the form of a transparent vesicle (Jceratocele), which fills the 
floor of the ulcer and may advance beyond the level of the cornea. If the 
perforation is small and central, the iris may not become prolapsed, but 
the lens is pushed forward and closes the opening. An exudate is poured 
out, and, after the aqueous humor reaccumulates and the lens resumes 
its normal position, a tag of exudate is found adhering to the anterior 
capsule of the lens. Thus there is formed an anterior polar cataract. In 
such cases repeated ruptures of the cicatrix may be followed by a permanent 
fistula of the cornea. While a perforation may be looked upon as an alarm¬ 
ing accident, as a matter of fact its influence upon corneal ulceration is 
generally favorable, by reason of the sudden reduction of tension permitting 
an improvement in the circulation of corneal fluids. 


PLATE XI. 

External Diseases of tha Eya. 




Fig. l. 

Interstitial Keratitis. 


Fig. 2. 

Creeping Ulcer of tha Cornea 
(Ulcus Serpens). 


Fig, 3. 

Blood-staining of the Carnea. 


Fig. 4, 

Staphyloma af tha Cornea. 


Fig, 5. 

Dendritic Keratitis. 


Fig. B. 

Panophthalmitis. 


\ 


Fig. 7. 

Large Corneal Scar. Iridectomy. 
Jirgyrosis of the Conjunctiva. 


Fig. B. 

Phthisis Bulbi. 










s .jil 

w=utin3 sdt la is a It3 jJfllgas'iO 
. (tneqT?2 uaaHT) 


IX 3.T.h:l r 'l 

.by 3L udj ia BoasBaltl iBniaixCI 

V) stjPPURATFVe KERATITIS. 


■»t' ii iitrnte does not undergo 
' 

• ■ * • ’e ri’auiiM,uions merge into olife 

< '■ « - ’••{-. »c lee Is :.••• %< i ,yrt | Hl'Seiit'.ed 

siJlJjg'japf leJlttetalcI :! 

:: •; ’ dpi cia; omeal layers'iindeigo 
ieat vi;i he external worl the <- 
h i a ■ • !C('' > ‘vi ral stages are reoognk.e l. 






.* ffT 

• ftaxmD bd.r In tuialxdq^JB 


•’ C"' ero/'fonl,* we speak of th» -date 
oi 1" • (u i shows signs of };••• ding. 
: -l. - : e. nn h i’goes healing, ve sp-ak 
M'e V.-” st re m variably leaves a scar of 
irde.i re> v ib die ranspnreney of the 
• ' 'ft ure ■ ke'l, it leads to perforation 

,!; i' ■■■ , fi 

• i IT <*;. r • .jsantoO *dti to g.aiittBlfetH&aoliH >‘- ; 

d 1 Ms. Vl lea ••»«; rg; - ui= ms a x*e nee. tag ary 
. m ra Jj into o<« non-..! front w ithout. 

1 ormal tissue from which the 

trauma ['he warnatS and 
to thfj growth of be Or 
■d nseptierillv 

' 


.ci .gl'T 

.atnfnCe.dliiqoxian ? Oifi 

uitlab.-isO 
>v;: jrgns 

r >f tlu eye, 

t c -cnee of iris- 

it the ulcer has 

mbrane of Doa- 

wii’ich fills the 

• cornea. If the 

- brolapsed, but 

* >iio is pouted 

h . i’ 1 resume* 

• A' .,8^ , . 

.-rmnlosttet .Wfc fheniuD sgaej 
.i^'irruitfjjcli sill to aJ&oTsfysfl. 

n 5>y a portna oeTit 
1 v'ry> ( ; apoa os an alarm- 
gdoal ulceration ia • 
'•■ion permitting 




,8 a/T 

.tele a smdiiM 




PLATE 11 











DISEASES OF THE CORNEA. 


309 


In case of perforation located outside the centre of the cornea, the 
iris becomes attached at the site of perforation, and remains there, forming 
an anterior synechia. The plugging of the perforation permits the rapid 
restoration of the anterior chamber, and, under favorable circumstances, 
healing takes place with the formation of a flat cicatrix. Under unfavorable 
circumstances, the prolapsed iris and cicatricial tissue are too weak to resist 
intra-ocular pressure, and a bulging scar, staphyloma of the cornea, results. 
Where practically the whole cornea perforates, there is a total prolapse of 
iris. Among the accidents following perforation are luxation or extrusion 
of the lens, the occurrence of intra-ocular hemorrhage, purulent irido¬ 
cyclitis, and panophthalmitis. In cases where these disastrous complications 
do not ensue, and where healing progresses favorably, a corneal scar results, 
which may be more or less opaque for many months or years. 

Etiology. —Corneal ulcers are classified etiologically as primary and 
secondary. The former begin in the cornea, while the latter are due to 
conditions located originally in tissues outside of the cornea. Primary 
ulcers result frequently from trauma of slight degree. The trauma may be 
the lodgment of a small foreign body which is driven into the cornea by the 
force of wind or by an explosion. It may come from the constant friction of 
misplaced cilia or by the rubbing of the roughened conjunctiva upon the 
globe. It may be due to wounds received accidentally or by operations; or, 
finally, it may be caused by burns, scalds, or escharotics. Secondary ulcers 
result from inflammations of the conjunctiva, disturbances in the tri¬ 
geminal nerve, or the existence of grave typhoid states. Extreme protru¬ 
sion of the eyes in exophthalmic goitre may lead to inability of the lids to 
protect the corneas, which slough. 

As regards age, corneal ulcers are exceedingly rare in children, except 
as a feature of phlyctenular keratitis or as following purulent, diphtheritic, 
variolar, or croupous conjunctivitis. In middle-aged and elderly persons 
they are very common. It is probable that such individuals possess slight 
resisting power to the invasion of bacteria, which are ever present in the 
conjunctival cul-de-sac , and are important factors in the etiology of corneal 
diseases. The microorganisms may be the ordinary pus-cocci, the gono¬ 
coccus of Neisser, the pneumococcus, or the colon bacillus. Serpiginous 
ulcers with hypopyon are almost invariably due to pneumococcic infection. 
Ulcers not typically serpiginous are generally due to the staphylococcus and 
streptococcus, but may result from the pneumococcus. In rare instances the 
sloughing ulcer is caused by schizomycetal infection: Aspergillus fumigatus. 
As regards social position, ulcers of the cornea are much more common 
among the poor and laboring classes than among the rich, the middle, and 
the professional classes. This is due to two factors: deficient nutrition and 
the liability to trauma among these unfortunates. 

Varieties of Ulcers of the Cornea. —Ulcers of the cornea present 
many clinical variations. Aside from the catarrhal ulcers which are men¬ 
tioned on page 253, and phlyctenular ones which will be considered under 


310 


MODERN OPHTHALMOLOGY. 


the head of “Phlyctenular Keratitis,” there are others, viz.: the simple 
ulcer, the round central ulcer, the rodent ulcer, the crescentic ulcer, the 
dendriform ulcer, the atheromatous ulcer, and the serpent ulcer. 

The Simple Ulcer, which may be secondary to the rupture of a phlyc¬ 
tenula, or primarily caused by trauma, presents itself as a small, superficial 
opacity, with loss of corneal substance and slight pericorneal injection. It 
may be simple or multiple, and tends to recur. While generally healing 
without incident, in the ill nourished it may be converted into a deep, 
purulent ulcer. Under the use of a boric acid solution these ulcers often 
heal readily. If due to phlyctenular disease, the ointment of the yellow 
oxid of mercury should be employed. In any event, attention to the general 
health will be in order. 

The Bound Central Ulcer , sometimes called the central, non-irritative 
ulcer, is indolent and stationary, often remaining for months. It is round, 
and is located over the pupil. Often it is clear at the bottom, but may show 
some infiltration. It is characterized by the absence of irritative symptoms. 
Vessels are commonly absent, and photophobia and lacrimation are not 
marked symptoms. Such ulcers occur in cases of chronic catarrhal con¬ 
junctivitis and in trachoma. They may remain superficial or may become 
deep and end in perforation or in the formation of a permanent scar. As 
regards treatment, any conjunctival disease present must receive appropriate 
attention. This, combined with the daily use of a 1-per-cent, strength solu¬ 
tion of boric acid, and the protection of the eyes by dark glasses, will suffice. 
Atropin is generally unnecessary in this form of ulcer. 

The Rodent Ulcer (ulcus rodens of Mooren) is an extremely rare con¬ 
dition, and occurs chiefly in advanced life. It generally develops at the 
corneal margin as a narrow, extended, superficial ulcer with noticeable 
inflammatory symptoms. It has undermined edges. The surrounding cor¬ 
nea is infiltrated, and from the limbus numerous vessels pass to the diseased 
area. Hypopyon is rare in rodent ulcer and perforation does not occur. 
Other infiltrated spots appear and undergo ulceration. These involve about 
one-third of the thickness of the cornea. They do not perforate, and are 
separated from the normal tissue by a grayish undermined margin. In heal¬ 
ing they leave a dense cicatrix. Soon other ulcers appear within the zone 
first attacked, and the process continues until the centre of the cornea, the 
last part to be involved, is affected. Commonly both eyes are involved and 
the patient is left blind. The course of the disease is slow and may last for 
months. As regards etiology, Andrade has examined two cases and has 
found a special bacillus which he believes is the pathogenic factor. The 
condition yields to the galvanocautery. Measures less heroic are useless in 
this disease. 

The Bing Ulcer , which appears, for the most part, in aged and decrepit 
subjects, begins near the limbus and extends around the circumference of 
the cornea. Thus, the nutrient supply is cut off and the whole cornea 
sloughs. Pain is not a prominent symptom in these cases. A common 


DISEASES OF THE CORNEA. 


311 


cause of ring ulcer is trauma. The disease is frequent among miners. A 
similar ulcer is sometimes seen in children as a result of phlyctenular disease. 

The only remedy for ring ulcer is destruction of the infected area, 
preferably by the galvanocautery. Eserin in weak solution (gr. 1 / 4 to §j) 
is useful. Hot applications can also be employed with benefit, but poultices 
are never in order. If perforation is threatened, eserin should be instilled 
and paracentesis should be performed. Later in the history of the case, or 
after the galvanocautery has been employed, atropin will be in order to check 
iritis. Tonics, antiperiodics, and, in suitable cases, stimulants are to be 
used. In the ring ulcer of children it will be necessary to use an ointment 
of the yellow oxid of mercury locally and to give attention to the general 
health. 

The Crescentic Ulcer, which generally appears at the upper part of 
the cornea, begins near the limbus. It is painful; photophobia and lac- 
rimation are marked symptoms. If unchecked, it leads to perforation. 
Usually it is due to catarrhal conjunctivitis. In simple cases the treat¬ 
ment of the affected conjunctiva by solutions of silver or of protargol or 
of argyrol will be required. 

The Dendritic Ulcer will be described under the name of “Malarial 
Keratitis.” 

A form of suppurative keratitis which, on account of its seriousness, 
demands special consideration, is the creeping, serpentine, or serpiginous 
ulcer. 

The Atheromatous Ulcer is found in old corneal scars and in staphy- 
lomatous eyes which have undergone hyalin degeneration with deposition 
of lime salts. Small pieces of lime may be found lying on the floor of the 
ulcer under a thick coating of pus. These ulcers tend to perforation and 
the consequent production of panophthalmitis. The atheromatous ulcer 
is primarily a necrosis, thus differing from the ordinary ulcer, which is 
primarily an infiltration. It differs from ulcus serpens in this respect, 
that the necrotic process extends only so far as is necessary for the seques¬ 
tration of a given portion of the corneal tissues (Fuchs). 

Creeping Ulcer of the Cornea (Hypopyon-Keratitis—Loser; 
Necrotic Corneal Abscess — Weber; Ulcus Corner Serpens—■ 
Saemisch ; Serpiginous Ulcer) .—This form of ulcer begins as a rounded 
spot of a yellowish or grayish-white color occupying the central portion of 
the cornea (Fig. 2, Plate XI). Its tendency is to spread peripherally. The 
opacity is greater at the margin of the ulcer than at the centre. In the area 
of propagation the margin is elevated and more yellow than in other places. 
Surrounding the ulcer is a zone of gray infiltration presenting striae. That 
part of the cornea corresponding to the ulcer is at first somewhat elevated, 
but soon becomes depressed. A violent iritis and the early appearance of 
hypopyon attest the severity of the pathologic process. Pain, photophobia, 
circumcorneal injection, and slight edema of the lids-are present in most 
cases. If the process is unchecked, great sloughing occurs with corneal per- 


312 


MODERN OPHTHALMOLOGY. 


foration, and vision is correspondingly reduced or entirely lost. When per¬ 
foration occurs, the hypopyon and aqueous humor are evacuated and the iris 
prolapses. In favorable cases perforation is followed by a scar, which may 
be flat or ectatic; in unfavorable ones panophthalmitis ensues, and the eye 
ends in phthisis bulbi. In favorable cases a dense scar is left in the cornea, 
the iris is adherent to the lens, and the pupil is occluded by a membrane. 
In unfavorable cases the destructive process is rapid. 

Etiology .—Creeping ulcer of the cornea may be found at any period 
of life, but is most frequent between the fortieth and seventieth years. 
Of 80 cases occurring in the Basel ophthalmologic clinic, reported by Wehrle, 
22.5 per cent, were poorly nourished, while 77.5 per cent, were in good 
condition. In 56 cases traumatism was present; in 3 exposure to cold was 
the supposed cause, and in 21 cases the cause could not be determined. 
Many of the patients presented chronic conjunctival and lacrimal diseases. 
Creeping ulcer is comparatively frequent among miners, vine-trimmers, 
harvesters, and others who are exposed to accidental injuries. As regards 
its bacteriology, it will suffice to say that recent investigations by Druault, 


0 


A B 

Fig. 221.—Appearance of the cornea in ulcus serpens. (Kxies.) 

A, In the height of the disease. B, After treatment by Saemisch’s incision. 

Petit, Coppez, Morax, Axenfeld, and others show conclusively that most 
cases of serpiginous ulcer of the cornea, and all typical cases, are due to 
the pneumococcus, which is found between the layers of the membrane. 
Other bacteria, particularly the staphylococcus and streptococcus, cause 
ulcers which are clinically similar to the pneumococc-ic ulcer. As mentioned 
above, trauma can be traced in a majority of serpiginous ulcers; and it 
is safe to assume that, in the remainder of the cases, slight injuries to the 
epithelial layer have permitted the bacteria to begin their invasion. In all 
cases of ulcerous keratitis there is microbic infection which is exogenous 
in type. Whether endogenous microbic infection of the cornea is possible 
is not known. 

In a large percentage of cases of ulcus serpens the patient suffers from 
trachoma or from a chronic inflammation of the lacrimal sac. In some 
instances he carries the infection by his handkerchief or bv usiner his 
saliva to moisten the eye. Ulcus serpens also occurs in variola, rubeola, 
typhus, scarlatina, etc. Fuchs states that the ulcus serpens of variola 
appears not in the height of the disease, but in the stage of desiccation; 





DISEASES OF THE CORNEA. 


313 


and, like the ulceration occurring in other infectious diseases, has been 
attributed to metastasis, but is more likely due to infection from without. 
Variolous ulcers are found in children as well as in adults, and often both 
eyes are affected. 

Pathology —This form of ulcer spreads both laterally and in depth. 
It often leads to perforation. Early in the history of the case intra-ocular 
disturbances are present, such as turbidity of the aqueous humor, the pres¬ 
ence of a fibrinous exudation on the lens and iris, detachment of the endo¬ 
thelium behind the ulcer, and the presence of a purulent exudation in the 
anterior chamber. Leucocytes are abundant in the tissues about the 
circumcorneal zone, in the anterior chamber, the ligamentum pectination, 
the posterior lamellae of the cornea, the endothelial layer, and in the iris. 



Fig. 222.—Creeping ulcer of the cornea. (Author.) 

(Photomicrograph by Dit. II. P. "Wells ) 


The extending ulcer presents overhanging margins. It may extend in one 
direction while healing in another. Numerous foci of inflammation appear, 
scattered over its floor. The corneal lamellae slough, down to the layer of 
Descemet. This rarely breaks down early. Generally it bulges forward as 
a transparent bleb, filling in the floor of the ulcer. V hen it ruptures, the 
aqueous humor escapes, the cornea collapses, and the lens either comes for¬ 
ward, blocking the rupture, or it escapes entirely from the globe. Perfora¬ 
tion may cause intra-ocular infection, ending in panophthalmitis, or the 
morbid process may show signs of improvement and the eyeball be saved. 

Prognosis of Corneal Ulcers. —However small and insignificant it 
may appear, a corneal ulcer is always an element of danger to visual acuity 
and even to the integrity of the globe. Early in the case the prognosis is 







314 


MODERN OPHTHALMOLOGY. 


usually favorable. However*, in cases of purulent conjunctivitis, in kera¬ 
tomalacia, and in serpiginous ulcers great damage will often result in 
spite of early and intelligent treatment. The prognosis of “foul” and 
extending ulcers is unfavorable, while if the ulcer becomes “clean” the 
outlook is favorable. When, in the course of a corneal ulcer, vessels extend 
from the limbus into the floor of the ulcer, the prognosis is good. 

Diagnosis. —The presence of an ulcer of the cornea is determined by 
inspection by natural or artificial light, with or without the aid of a mag¬ 
nifying glass. In cases of blepharospasm the use of holocain will facilitate 
the examination. In children it often is necessary to use lid-retractors. 
To determine the exact limits of an ulcer the surgeon can use a 2-per-cent, 
strength solution of fluorescin, which stains the denuded part of the cornea 
a greenish tint, in marked contrast to the surrounding normal tissue. 

Treatment of Corneal Ulcers in General. —In the treatment of 
corneal ulcers the principles to be kept in mind are: 1. Removal of the 
cause. 2. Limitation of the pathologic process and prevention of perfo¬ 
ration. 3. Promotion of the reparative process. 4. Removal, so far as 
possible, of the effects of ulceration. 

1. The removal of foreign bodies lodged in the cornea or conjunctiva, 
or of cilia rubbing on the globe, will be in order. Since many cases of 
corneal disease are dependent on affections of the conjunctiva, it will be 
more necessary to direct treatment to the latter than to the former. 

2. To limit the pathologic process and prevent perforation is usually 
an easy task if the patient comes early; but under other circumstances it 
may be impossible. The chief agents in limiting the spread of an ulcer 
are various antiseptics and caustics, such as bichlorid of mercury, formalin, 
tincture of iodin, carbolic acid, and, best of all, the galvanocautery. The use 
of atropin solution is valuable because of its effect on the accommodation and 
blood-vessels, and because it also prevents iritic adhesions. On account of its 
constitutional effects it must be used cautiously in children. In cases where 
the pupil does not enlarge under its application, particularly where old 
and firm synechias are present, atropin will best be dispensed with, for the 
reason that it may produce increased intra-ocular tension. In deep periph¬ 
eral ulcers which are likely to perforate it should not be used; in such 
cases eserin or arecolin will be better than atropin. As a rule, the use of 
a bandage is to be prohibited. It never should be employed where secretion 
is profuse, since here it becomes moistened and hot, and acts as a poultice. 
The chief arguments in favor of a protective bandage are that it keeps dust 
from the eye and prevents movement of the globe. In order to immobilize 
the affected eye, however, it will be necessary to bandage both eyes. Poul¬ 
tices, which are so popular with the laity, have no place in modern oph¬ 
thalmology. They are not only useless, but often are positively harmful. 
The eyes should be protected from light by smoked glasses. The intermit¬ 
tent application of moist heat is often of benefit. It can be applied by 
pouring boiling water on a towel and placing this, when somewhat cooled. 


DISEASES OF THE CORNEA. 


315 


upon the closed eyelids, leaving it in position for two to five minutes and 
repeating; or the same effect can be obtained by pouring the water into a 
glass brim full, and having the patient immerse his eye with the lids closed. 
These applications of moist heat can usually be repeated every three or four 
hours with benefit. They relieve pain and allay congestion. The collyria 
used should generally be soothing and non-astringent. Collyria leading to 
a metallic deposit in the cornea, such as lead acetate, should not be used. 

Where perforation seems impending, daily paracentesis of the cornea, 
the application of a bandage, and the use of a miotic to reduce intra-ocular 
tension will be in order. The subconjunctival injection of a solution of 
bichlorid of mercury, which has been advocated by Beymond and Secondi, 
of Turin, and Darier, of Paris, is an efficient means of checking corneal 
necrosis and clearing up an hypopyon. After the local use of cocain, the 
injection is made, a Pravaz syringe being used. The solution may vary in 
strength. Gargarin, of St. Petersburg, used a 1 / 10 -per-cent. solution; 
Secondi uses a solution composed of 1 part of sublimate and 2 parts of 
sodium chlorid dissolved in 2000 parts of water. The amount to be injected 
varies from a few drops to one-half of the capacity of the Pravaz syringe. 
Darier injects a solution of cyanid of mercury (1 to 4000). To make the 
injection painless, he uses cocain or holocain locally and adds a few drops of 
a 1-per-cent, strength solution of acoin to the cyanid solution. These 
injections are sometimes followed by burning pain lasting for an hour, 
edema of the bulbar conjunctiva, and swelling of the upper eyelid, hle- 
crosis of the conjunctiva at the site of the injections may ocur. On 
account of these untoward effects of sublimate injections, Mellinger and 
others have abandoned the sublimate for a normal salt solution, which is 
efficient and non-irritating. Wehrle, in comparing the effects of linear 
cauterization, subconjunctival injections of sublimate, and subconjunctival 
injections of salt solution in the treatment of hypopyon keratitis, gives 
preference to the salt solution. If, under the plan of treatment outlined 
above, the ulcer continues to spread, it will be advisable to use the galvano- 
cautery. Its application is often followed by marked improvement, a foul 
ulcer becoming clean and repair ensuing. If the surgeon does not wish to 
use the cautery, he can curette the ulcer and apply tincture of iodin, a 
strong solution of nitrate of silver, or a drop of pure carbolic acid. A 10- 
per-eent. solution of pure nitric acid, applied by means of a wooden appli¬ 
cator, is a valuable caustic for serpiginous ulcers. In this kind of an ulcer 
the operation known as Saemisch’s incision is often followed by great im¬ 
provement. In this procedure a cataract-knife is passed through the cornea 
and the hypopyon is evacuated either spontaneous^, or, if thick, is seized 
with forceps and drawn out. 

3. The reparative process is promoted by the measures just described. 
Moist heat favors the separation of necrotic from living tissue, promotes the 
necessary development of new blood-vessels in the cornea, and relieves pain. 
It is particularly valuable in subacute ulcers. Puncture of the base of the 


316 


MODERN OPHTHALMOLOGY. 


ulcer or paracentesis external to it, in cases of impending perforation, is 
often useful, since it reduces tension, starts a flow of lymph into the cornea 
from its nutrient vessels, and promotes repair. The same effect results from 
the corneal incision of Saemisch in serpiginous ulcers. Chandler and Bisley 
have found the use of a 10-per-cent, ointment of cassaripe, a vegetable anti¬ 
septic, of great value in the treatment of corneal ulcers. The observance of 
ordinary hygienic rules and the use of tonics, antiperiodics, and sometimes 
of stimulants will be in order in corneal ulcerations in the aged. 

4. The removal of the effects of ulceration must take into consideration 
the immediate effects (complications) and those which are remote (sequelai). 
The complication most to be dreaded is perforation with prolapse of the 
iris. If the patient is seen shortly after the occurrence, it will be advis¬ 
able to use a general anesthetic, draw the iris forward through the opening, 
and excise it close to the cornea. The angles of the iris-coloboma are then 
to be Stroked back into place by means of a spatula. Gamo Pinto follows 
this procedure by placing an excised piece of conjunctiva, twice as large as 
the original opening, between the lips of the corneal opening. A com¬ 
pressing bandage is then applied. This method will sometimes result in the 
formation of a flat scar without anterior synechia. The treatment of other 
complications and of the sequelae of corneal ulcers will be discussed else¬ 
where in this chapter. 

Neuroparalytic Keratitis (Neuropathic Keratitis). — This name is 
applied to the condition of the cornea which follows paralysis of the oph¬ 
thalmic division of the fifth nerve. 

Etiology. —Paralysis of the ophthalmic division of the fifth nerve 
may be due to any one of many causes: tumors in the pituitary region or 
at the base of the brain; syphilitic, traumatic, or epidemic meningitis; 
caries of the temporal bone; fracture of the skull; primary neuritis, a rare 
cause; disease of the nuclei of the trigeminal nerve; or operation for 
removal of the Gasserian ganglion for the cure of neuralgia. Whether the 
lesion is located in the nerve-trunk or in its nuclei of origin in the brain, 
the result is the same. In paralysis of the fifth nerve winking and lacrima- 
tion do not occur; hence the cornea becomes dry and minute foreign bodies 
settle upon it. Infection takes place and destruction of tissue follows. 
Since the time of Magendie it has been customary to attribute neuro¬ 
paralytic keratitis to the loss of the influence of trophic nerve-fibres sup¬ 
posed to be located in the trigeminus, but in the light of modern pathology 
it is no longer necessary to adopt this hypothesis. Snellen’s explanation, 
that the insensibility of the eye occurring in paralysis of the fifth nerve 
enables ordinary causes to act unmolested on the cornea, is now generally 
accepted. 

Symptoms. —The chief symptom is anesthesia. In paralysis of the 
entire fifth nerve or of its ophthalmic branch, both cornea and conjunctiva 
become anesthetic. After optico-ciliary neurectomy the cornea alone is 
anesthetic, winking and lacrimation remaining and no harm resulting to the 


DISEASES OF THE CORNEA. 


317 


cornea. If, however, the branch of the seventh nerve supplying the orbicu¬ 
laris muscle is paralyzed, the cornea is likely to slough. Neuralgic pain, 
through the region supplied by the affected ophthalmic branch of the fifth 
nerve, may precede the anesthesia. There may be loss of taste on one side 
of the tongue; and the motor root may also be involved, as is evidenced by 
paresis of the masseter, temporal, and external pterygoid muscles. Local¬ 
ization of the pathologic process is often possible b) r a study of the extent 
of the anesthesia and of the associated conditions. For this information 
the reader is to consult the standard works on neurology. 

Following paralysis of the fifth nerve the cornea becomes cloudy, the 
epithelium of its centre is loosened and removed, and this process extends 
until only a narrow peripheral rim remains. The central ulcer is at first 
gray; then it becomes yellowish, hypopyon forms, the ulcer perforates, and 
the iris is engaged in the cicatrix. Healing is followed by a flat scar. Not 
every case runs a course so severe as this, since the process may not lead 
to perforation. In neuroparalytic keratitis ciliary injection is present, but 
lacrimation is absent. 

The corneal changes following excision of the Gasserian ganglion can 
be prevented by stitching the lids together and at the first dressing applying 
a Buller shield. If these precautions are not observed, the cornea may 
necrose and the eye be lost. In necrosis and suppuration of neuroparalytic 
keratitis, pain, lacrimation, and blepharospasm are absent. Ocular tension 
is usually reduced. 

Prognosis. —Neuroparalytic keratitis is always a serious disease. If 
treated early and properly the process can usually be checked and useful 
vision can be saved. In such cases, after restoration of tissue has occurred, 
an iridectomy may improve vision. 

Treatment.— The preventive treatment has been mentioned above. 
The curative treatment consists in the application of a bandage, the use of 
atropin or eserin, and the frequent cleansing of the eye with an antiseptic 
solution. Electricity may be tried. Nieden advises the hypodermic injec¬ 
tion of strychnin in the temple. 

Lagophthalmic Keratitis (Keratitis e Lagophthalmo).—Keratitis from 
drying of the cornea due to imperfect closure of the eyelids may be at¬ 
tributed to many causes. It is found in paralysis of the orbicularis muscle 
in persons suffering with profound exhaustion (typhoid fever, uremic coma, 
etc.) ; in cases of destruction or cicatricial contraction of the eyelids; 
in caries of the orbital margin, producing ectropion; and rarely in ex¬ 
ophthalmic goitre when the exophthalmos is excessive. As a result of 
desiccation the cornea becomes fissured, and pathogenic germs, gaining a 
foothold, soon cause suppurative inflammation. Hypopyon, iritis, and ex¬ 
tensive ulceration of the cornea are common, while perforation and total loss 
of the eye are not rare. ‘‘The corneal ulcer is distinguished by its location 
at the lower edge of the cornea, by its sharply divided upper edge parallel 
to the margin of the upper lid, and, finally, by the fact that a dry scale is 


318 


MODERN OPHTHALMOLOGY. 


first produced, the ulcer not being visible until the scale is thrown off’ 
(Fick). The general course of the disease resembles that of neuroparatytic 
keratitis. The prognosis is serious, and particularly is it grave in the 
corneal ulceration of exophthalmic goitre. 

Treatment. —If possible, the cause should be removed. The cornea 
must be protected, and, in case a bandage does not suffice, the operation 
of uniting the eyelids (tarsorrhaphy) will be in order. It is customary to 
make a partial union of the eyelids, the outer portion being usually selected 
for operative intervention, although it may be deemed advisable to unite 
the middle third of the lids. 

While the operation of partial tarsorrhaphy has generally been regarded 
as harmless, in cases of exophthalmic goitre it has sometimes been followed 



Fig. 223.—Keratitis e lagophthalmo. (Author.) 

(Original drawing by Du. Caul Fisch.) 


by disastrous results. Jessup says: “l should hesitate to again employ it 
in such cases, or at all events in a patient over thirty-five years old. As 
soon as the cornea was affected in my case, no treatment seemed to have the 
slightest effect in staying the ulceration.” In milder forms of lagophthalmie 
keratitis the affected eye should be bandaged at night. Atropin and mild 
antiseptic washes are to be used and all sources of irritation are to be 
avoided. 

Xerophthalmic Keratomalacia (Xerotic Keratitis; Simple Kerato¬ 
malacia; Infantile Ulceration of the Cornea with Xerosis of the Conjunc¬ 
tiva).—This rare disease, which was first described by von Graefe, usually 
appears in marasmic children during the first four years of life. In a case 
observed by the author, a boy, aged 3 years, after a prolonged attack of 


DISEASES OF THE CORNEA. 


319 


diarrhea presented conjunctival xerosis of both eyes. Later the cornea 
became infiltrated near its periphery and also in the centre. The bulbar 
conjunctiva, particularly that part corresponding to the palpebral opening, 
presented a frothy, grayish, silvery appearance due to exfoliation of epi¬ 
thelium. There was diminished sensitiveness of the cornea and of the con¬ 
junctiva. 

A form of xerotic keratitis occurring frequently among negro children 
has been described by Ivollock, of Charleston, S. C. In his cases, which 
occurred chiefly among scrofulous, emaciated subjects, the interpalpebral 
part of the conjunctiva presented a dirty-white, yellowish-green hue. In 
some cases the ocular conjunctiva was thickened and discolored; in others 
it was relaxed and flabby and was thrown into folds about the cornea by 
the movements of the globe, and “occasionally these folds were capped by 
the silvery scales which some writers have described as being diagnostic of 
hemeralopia.” In the disease under consideration night-blindness is rarely 
the cause of the child being brought to the surgeon, since the affection occurs 
in persons so young that usually they either do not go about unattended or 
cannot describe their symptoms accurately. 

The chief danger in this disease is corneal ulceration. In some pa¬ 
tients the corneal infiltration, which is present in all cases, does not go on 
to ulceration. When ulceration occurs it often assumes the form of a ring, 
which may be elevated or depressed. The centre of the cornea may or may 
not be clear. The whole cornea presents a bluish, hazy sheen, due to opacity 
of the epithelium, which in rare instances is raised into folds. Perforation 
of the cornea may occur. Iritis without perforation is rarely observed. 
Pain, photophobia, and lacrimation are absent in xerotic keratitis. Spicer 
has observed cases in which xerosis of the conjunctiva was absent. 

Etiology. —The cause of this disease is unknown. It follows ex¬ 
hausting diseases, such as typhoid fever, meningitis, and chronic diarrhea. 
Various bacilli and cocci have been found in these cases, but it is not known 
whether they are etiologic factors. The disease is more common in Austria 
than in America. In this country it seems to occur more frequently among 
negro than among white children. Ivoller states that the disease is some¬ 
times epidemic, especially in orphan asylums, and attributes it to reflection 
from a body of water or from a white wall. 

Prognosis. —According to Swanzy and others who have observed the 
disease in European clinics, xerotic keratitis is almost always followed by 
death from exhaustion. In Kollock’s cases benefit followed treatment and 
no mention is made of a fatal result. 

Treatment. —The weakened constitution must be strengthened by 
tonics, stimulants, and proper food. Change of air and surroundings may 
be beneficial. As the strength grows the ocular condition will improve. 
Locally vaselin or a weak ointment of the yellow oxicl of mercury (gr. ij to 
oiij), or a solution of boric acid may be applied. When there is corneal 
ulceration, atropin will be in order. 


320 


MODERN OPHTHALMOLOGY. 


(B) NONSUPPURATIVE KERATITIS. 

Phlyctenular Keratitis (Eczematous, Scrofulous, or Strumous Kera¬ 
titis; Fascicular Keratitis).—This disease, which should be studied in 
connection with phlyctenular conjunctivitis, is a common one, character¬ 
ized by the development of phlyctenulae on the cornea instead of the con¬ 
junctiva or limbus, as in phlyctenular conjunctivitis. Often both conjunc¬ 
tiva and cornea are involved at the same time. The causes of phlyctenular 
keratitis are the same as those of phlyctenular conjunctivitis. The disease 
is much more frequent in children than in adults, and is closely connected 
with disorders of the nasal passages (adenoid vegetations, hypertrophic or 
atrophic rhinitis, etc.). It often follows measles and other exanthemata. 

Symptoms. —The first change in this disease is the appearance of 
collections of round cells beneath the epithelium, which is lifted up. This 
constitutes a corneal phlyctenula. It is usually situated at or near the 
corneoscleral junction. It varies from a poppyseed to a milletseed in size, 
and changes in color from gray to yellow in the course of a few hours. 
Soon it bursts, leaving a small ulcer,— phlyctenular ulcer, —and coincidently 
pain, photophobia, blepharospasm, and lacrimation become pronounced 
symptoms. The conjunctival and pericorneal vessels in the vicinity of the 
ulcer become engorged, and frequently there is a muco-purulent discharge 
from the conjunctiva. The ulcer may heal rapidly or may remain, other 
phlyctenulae appearing and going on to the formation of ulcers. On the 
other hand, the process may disappear by absorption of the contents of the 
phlyctenula. If the ulcers heal before the deeper layers of the cornea are 
involved, only a faint nebula remains, and this in young subjects disappears 
entirely in the course of a few months or years. Often, however, the process 
is not favorable. The ulcers spread in breadth and depth, are surrounded 
by a deeply placed zone of grayish or yellowish infiltration, and may even 
lead to perforation of the cornea. Meanwhile vessels extend from the limbus 
to the ulcer, and these, when in the form of a leash or band, make part of 
a clinical picture which has been named fascicular keratitis (Fig. 8, Plate 
X). If a number of phlyctenulas develop along the rim of the cornea, the 
condition may be named marginal phlyctenular keratitis. Instead of ap¬ 
pearing as one or more clearly defined ulcers, the disease may present a 
thick tongue of vascularized tissue growing from the limbus toward the 
centre of the cornea— pannus eczematosus. Unlike the pannus of trachoma, 
this affection does not show a predilection for the upper part of the 
cornea, but often appears below or at the inner or outer side. Pannus 
eczematosus usually clears up satisfactorily under treatment, leaving only 
a slight opacity. The single pustule, which usually appears at the corneal 
periphery, is particularly dangerous, and is liable to cause perforation when 
surrounded by a yellowish, infiltrated area. Iritis and hypopyon often 
accompany it. 

The intensity of the subjective symptoms is not a criterion of the 
gravity of the pathologic process. Often children present intense blepharo- 


DISEASES OF THE CORNEA. 


321 


spasm, profuse lacrimation, and great photophobia, with relatively small 
corneal changes. The child keeps in the dark, buries the head in a pillow 
or the mother's lap, and screams when exposed to light. Under these cir¬ 
cumstances inspection of the cornea is difficult and requires the use of lid- 
retractors. The reflex blepharospasm of this disease was explained many 
years ago by Iwanoff, who demonstrated the migration of. round cells 
from the corneal margin to the pathologic focus under the epithelium. 
Thus, irritation of the nerve-filaments, whose course they follow (Fig. 224), 
is produced. A strange effect of long-continued blepharospasm, which has 
not been satisfactorily explained, is the occurrence of temporary amaurosis. 
In these cases there are no ophthalmoscopic changes. The patient usually 
regains vision in a few weeks. A persistent eczema of the nose, face, and 
ear, and chronic rhinitis, are common accompaniments of phlyctenular 
keratitis. 



N 


Fig. 224.—Section of the cornea in phlyctenular keratitis. 

(After Iwanoff.) 

E, Epithelium. P, Round-cell infiltration. C, Substantia propria. N, Corneal nerve. 

B, Bowman’s layer. 

Pathology and Diagnosis are given under the heading of “Phlyc¬ 
tenular Conjunctivitis” (page 272). 

Prognosis. —If treatment is begun early the prognosis is favorable, 
healing occurring with only slight opacity. In severe types a perceptible 
scar remains. In neglected cases perforation of the cornea may occur. 

Treatment. —The regulation of the diet and attention to the general 
health, as well as the treatment of naso-pharyngeal conditions will be in 
order here as in phlyctenular conjunctivitis (see page 274). Locally at- 
ropin drops and ointment of the yellow oxid of mercury (gr. j to oj) should 
be used daily and should be continued for some time after all signs of the 
disease have disappeared. Darier claims that a 1-per-cent, strength solution 
of dionin, by its lymphagogic and analgesic properties, is of value in the 
treatment of phlyctenular keratitis. 

Interstitial Keratitis (Specific, Parenchymatous, or Strumous Kera¬ 
titis; Keratitis Profunda)—This is a chronic inflammation of the middle 
and posterior layers of the cornea, occurring chiefly in children, not leading 









322 


MODERN OPHTHALMOLOGY. 


to ulceration, but accompanied by inflammation of the uveal tract. There 
is in these cases a deposit of new material in the cornea and a development 
of new blood-vessels. 

Etiology. —From the records of many large clinics it is found that 
hereditary syphilis is the cause of interstitial keratitis in from 40 to 97 
per cent, of the cases, thus confirming the opinion which was expressed by 
Hutchinson many years ago. The disease also may occur late in the history 
■of acquired syphilis. Certain cases of interstitial keratitis are due to herpes 
poster ophthalmicus.' It is supposed that some cases of interstitial keratitis 
are of tuberculous origin (von Hippel). Although it may be an intra-uter- 
ine disease, interstitial keratitis generally occurs between the fifth and twen- 



Fig. 225.—Section of the cornea in interstitial keratitis. (Baas.) 

1, Epithelium. 2, Bowman’s layer. 3, Area of infiltration. 4, Membrane of Deseemet. 

5, Endothelium. 


tieth years. It is rarely observed after the thirtieth year. It is seen oftener 
in females than in males. In the victims of hereditary syphilis slight 
causes—such as eyestrain, irritants, rheumatism, and other acute diseases— 
suffice to produce the initial changes of interstitial keratitis. 

Symptoms. —Patients with interstitial keratitis often show the signs 
of hereditary syphilis. Chief amopg these are the following:— 

1. A peculiar physiognomy. “The conformation of the face is some¬ 
what angular, the features are contracted and drawn, the skin is coarse, 
and the complexion is pale and earthy. The forehead is prominent, and 
the skin covering it is thrown into wrinkles through the frowning incidental 
to the long suffering from fear of light. The bridge of the nose is de¬ 
pressed, and may be completely sunken, through the loss of the bones from 


DISEASES OF THE CORNEA. 


323 


syphilitic ulceration; from a similar cause affecting the skin, the angles 

o j o 

of the mouth and the alje nasi are scarred and fissured by white cicatrices.” 
(Ramsay.) 

2. The teeth are notched or pegged in 60 or 70 per cent, of the cases. 
Often they are irregularly placed and are stunted in their growth. Of the 
dental malformations, the most characteristic is the notching of the upper 
central permanent incisors. 

3. The lymphatic glands, especially those of the neck, are enlarged, 
hard, and painless. Unlike the enlarged glands in scrofulous persons, they 
do not readily become swollen, soft, and caseous. 

4. The periosteum, particularly that covering the long bones, presents 
swellings which are hard and usually painless. 

5. Impairment of hearing, leading frequently to absolute deafness, is 
a common condition in these patients, and is due to the extension of nose 
and throat lesions into the middle ear. 

It is rare to find all of these signs present in one individual; if a few 
of them are found, they form reliable evidence of the hereditary taint. 



Fig. 226.—Notched teeth. (De Beck.) Fig. 227.— Pegged teeth. (De Beck.) 


Interstitial keratitis begins with photophobia, lacrimation, pericorneal 
injection, and blurring of vision. The cornea becomes hazy either at its 
periphery or at the centre; the haziness may be general or circumscribed. 
When the opacity extends, the cornea looks like a piece of ground glass. 
Under a magnifying lens it is seen to be studded with minute maculae, which 
are deeply placed. Early in the history of the case vision is much reduced, 
and blood-vessels are found in both the deep and superficial layers of the 
cornea. As the vessels extend the ground-glass appearance is replaced by 
reddish “salmon patches” (Fig. 1, Plate XI). These may appear above, 
below, at either side, or they may involve the wdiole cornea. In this stage the 
cornea is softened and its curvature may be changed by pressure of the lids; 
photophobia and blepharospasm are intense, and fissures appear at the outer 
canthus. These symptoms continue with intermissions for weeks or months. 
In some cases years pass before the disease stops. The complications of in¬ 
terstitial keratitis are iritis, cyclitis, and chorioiditis, which generally appear 
early, but may not come until late. The second eye is always involved, with 
few exceptions; usually the disease has progressed to its height in the one be¬ 
fore the other eye is affected. During the acute period of the inflammation 






324 


MODERN OPHTHALMOLOGY. 


the cornea appears white, gray, or yellow according to the amount of infiltra¬ 
tion present, and the condition may be mistaken for corneal abscess. The 
new vessels arising in interstitial keratitis spring from the deeply placed 
vessels of the sclera and project into the cornea in the form of tufts. These 
vessels grow into the membrane until the pupil is concealed. They may be 
small and invisible except through a corneal microscope or magnifying 
glass, or so large as to be readily seen by the naked eye. 

Gradually the acute symptoms subside and the cornea begins to clear, 
the clearing beginning at the margin. In favorable cases the healing process 
lasts from nine to twelve months. Long after the disappearance of the 
attack the surgeon will know that such an eye has been affected by this 
disease, by reason of a peculiar lustreless appearance of the iris seen through 
a cornea that is slightly opaque. The anterior chamber is deeper than in 
the normal eye, and the ophthalmoscope shows the signs of a previous 
chorioidoretinitis. Close examination shows in the cornea the remains of 
old vessels. 

Pathology. — Interstitial keratitis usually manifests itself at the 
corneoscleral margin, as an opacity in the deeper corneal layers, which 
gradually invades the cornea until the entire membrane is cloudy. If the 
infiltration is dense and the vascularization plentiful, the cornea becomes 
salmon colored. The cloudiness is accompanied by a small-cell infiltra¬ 
tion, which may be very dense in the deeper layers. Besides this, new- 
formed vessels are found. The whole may resemble granulation tissue 
(Fuchs). The infiltration is also found in the ligamentum pectinatuuq in 
the iris and the ciliary body, and sometimes in the sclera. Yon Michel and 
others distinguish between a primary and a secondary parenchymatous kera¬ 
titis. The opacity appears first at the limbus; and is complicated later by 
iritis, turbidity of the aqueous humor, and deposits on Descemet’s mem¬ 
brane. Yon Michel explains the disease as a consequence of syphilitic arte¬ 
ritis or hyalin degeneration of the pericorneal vascular loops. 

He is opposed by Leber and von Iiippel, who consider the affection as 
a secondary manifestation which is primarily an inflammation of the uvea. 
The anatomic findings of von ILippel, the infiltration in the deeper por¬ 
tions of the cornea, which embryologically is the uveal portion of the cornea, 
and the black patches which are in the periphery of the chorioid at the be¬ 
ginning of an interstitial keratitis, all support the latter view. Wagenmann 
produced a condition resembling this affection by cutting the two long and 
some of the short ciliary vessels. He concluded that the seat of the disease 
was to be sought in the chorioid. 

Diagnosis. —Attention to the symptoms described above will clear the 
diagnosis. The age of the patient and the condition of ocular tension will 
exclude primary glaucoma. The history of the case will serve to differ¬ 
entiate parenchymatous keratitis from recent infiltration due to trauma. 

Prognosis.— Interstitial keratitis is a chronic disease lasting from a 
few weeks to many months. In general terms it must be said that the 


DISEASES OF THE CORNEA. 


325 


prognosis is favorable, since recovery of useful vision occurs in the great 
majority of cases. In scrofulous subjects the prognosis is not so favorable 
as in those of a purely syphilitic type. Recurrences of interstitial keratitis 
are rare and may come years after the primary attack. Restoration of 
normal vision is not to be expected in this disease, but the resulting opacity 
may be scarcely distinguishable. If improperly treated, the result may be 
disastrous through the formation of iritic adhesions, increased intra-ocular 
tension, etc. The duration of an attack of interstitial keratitis cannot be 
foretold. Early in the disease it is well to warn the patient that the vision 
will become much worse, while in the height of the attack he can be told 
that it will improve. In general, the prognosis is more favorable in adults 
than in children. 

Treatment. —While some eminent observers hold that the disease is 
uninfluenced by treatment, the author believes such teaching to be pernicious 
and sometimes destructive. Although the therapeutic agents may not 
shorten the duration of the disease, it is not the less necessary that means 
should be employed to relieve pain and inflammation and keep the iris out 
of the way of harm. Both constitutional and local measures are to be used. 
Attention to the digestion, the taking of a reasonable amount of exercise, 
and the leading of an outdoor life will be in order. The internal use of 
mercurial preparations and bitter tonics is to be commended. Hutchinson’s 
view of the value of mercury has been confirmed by many able clinicians. 
Codliver-oil, iron, and quinin can be used at the same time. If definite 
signs of hereditary syphilis are absent, it will nevertheless be wise to use 
mercury for several weeks or months. The remedy can be given by the 
month or preferably by inunction. Care must be taken to avoid ptyalism. 
Later in the case the iodids are serviceable. In weak cachectic subjects, mer¬ 
cury should be used sparingly and tonics should be exhibited freely. The 
syrup of the iodid of iron is a valuable remedy in these cases. 

As regards local treatment, smoked glasses are to be used and atropin 
is to be instilled three times a day. The use of atropin must be continued 
long after the opacity renders the pupil invisible. It must be used freely, 
because the absorptive power of the cornea is diminished. The use of hot 
water is valuable in relieving pain. After the acute stage is over the daily 
application of an ointment of ammoniated mercury or the yellow oxid, com¬ 
bined with massage, will assist in clearing the opacity. Astringents and 
counter-irritants are to be avoided. 

Vascular Keratitis (Pannus).—Of the forms of non-suppurative kera¬ 
titis, this is, by far, the most frequent. Pannus is a small-cell infiltration 
containing newly formed vessels and involving the conjunctival (i.e., super¬ 
ficial) layers of the cornea (Fig. 2, Plate X). The infiltration is in the 
deeper parts of the epithelial layer, and here there is a development of minute 
blood-vessels continuous with those of the limbus. The newly formed con¬ 
nective tissue is found chiefly between the epithelial and Bowman layers, but 
in some cases the process extends more deeply and involves the substantia 


326 


MODERN OPHTHALMOLOGY. 


propria. It is proper to state that some authorities (Kaehlmann, Fuel) 
have found the process in pannus to begin in a cellular infiltration beneath 
Bowman’s membrane, which is lifted up, wrinkled, and finally perforated. 
Pannous tissue is thicker at the periphery of the cornea than at the centre; 
thus, at the periphery all the layers, down to that of Descemet, may be in¬ 
volved, while in the centre usually only the parts adjacent to Bowman’s layer 
are affected. True trachoma bodies may be found in the corneal substance. 
Vascular keratitis exists in almost all cases of granular conjunctivitis, and 



Fig. 228.- —Trachoma with pannus. (Author.) 

(Original drawing by Dr. R W. Mills.) 

is often found in phlyctenular kerato-conjunctivitis. The development of 
vascular keratitis leads to irregularities in the corneal surface, to great 
diminution of vision, and in some cases to projection of the softened cornea 
from intra-ocular pressure. 

Symptoms. —Clinically it is necessary to divide pannus into several 
types, the appearance of the cornea varying from a slight vascular opacity 
to a condition comparable to raw flesh or a red rag. “In former times the 
adjective tenuis was used to indicate a thin layer of opacity, in which few 
vessels were present; crass us , a thicker and more advanced condition; sar- 


DISEASES OF THE CORNEA. 


327 


comatosus, a fleshy state of the cornea; while siccus was applied to a pannus 
that had undergone retrogressive changes” (Stephenson). Pannus gener¬ 
ally is limited to that part of the cornea which is covered by the upper lid, 
but there are many exceptions to this. Thus, in the pannus of phlyctenular 
disease it is not uncommon to find broad, tongue-like vascular projections 
growing—one from above, the other from below—toward the centre of the 
cornea; and frequently, in severe granular conjunctivitis, the whole cornea 
becomes vascular. Pannus usually shows ulceration at some time in its his¬ 
tory, but there are cases in which this is absent and the condition is one of 
hypernutrition. In typical pannus the upper third or half of the cornea 
is involved; numerous small, straight vessels, continuous with the posterior 



Fig. 229. —Section of the cornea in pannus. (Author.) 

(Original drawing by Dr. Carl Fisch.) 

1, Degenerated epithelium. 2, Area of round-cell infiltration. S, Substantia propria. 

4, Blood-vessels. 

conjunctival system, are seen branching arborescently into a grayish opacity; 
and the epithelium is elevated and roughened. Vision is much reduced 
during the active period of the pannus, and later the sight in many cases is 
below the normal by reason of the irregular astigmatism and remaining 
opacities. When the pannus is thin, complete restoration will take place. 

Pannus appears in the early stages of trachoma and almost never arises 
in the cicatricial stage. Pelapses are common; they appear suddenly and 
seem to be provoked by meteorologic conditions, such as excessive humidity 
of the atmosphere or increased velocity of the wind. The signs of relapse 
are unmistakable: the conjunctiva becomes redder and thicker, the cornea, 
which possibly had cleared so that vessels were scarcely visible, becomes 





328 


MODERN OPHTHALMOLOGY. 


studded with vessels; in two or three days small superficial ulcers appear; 
and pain, blepharospasm, photophobia, and lacrimation become prominent 
and annoying symptoms. Vision is rapidly reduced. A patient whose 
cornea’was almost clear, in less than a week was reduced to a condition 
requiring the services of a guide. 

Diagnosis. —The diagnosis of pannus is easily made by inspection by 
the naked eye or with the aid of a magnifying glass. To distinguish be¬ 
tween the granular, phlyctenular, and traumatic varieties of corneal vas¬ 
cularization is an easy matter, in view of the history of the case and the 
condition of the palpebral conjunctiva. 

Prognosis. — Granular pannus is an extremely persistent affection, 
the state of the cornea keeping pace with the condition of the conjunctiva. 
Generally the cornea clears, leaving useful vision; but in some cases pannus 
crassus lasts for years and destroys vision by causing permanent opacities. 
In other instances ulcers of the cornea accompanying pannus become in¬ 
fected, the cornea sloughs and is perforated, and the eye is left with anterior 
synechia} and a staphyloma. In severe cases perforation is followed by 
panophthalmitis and loss of the eye. In many cases where’ pannus yields 
successfully to treatment, the cornea is left irregularly astigmatic. Recur¬ 
rence of granular pannus is likely to take place at any time so long as the 
conjunctiva is granular. 

The pannus accompanying phlyctenular disease generally yields 
promptly to treatment, leaving the cornea either unimpaired or the seat 
of a small cloud. Some cases, however, are followed by permanent opacities. 

Treatment. —The treatment of pannus will depend on its cause and 
stage. In granular pannus, as a rule, little care is given to the pannus 
proper, the surgeon’s attention being devoted to the conjunctiva. In the 
ordinary cases of trachoma treatment of the conjunctiva is followed by 
improvement in and disappearance of the pannus. In old cases, where, 
in spite of conjunctival treatment, the cornea remains vascular, it will be 
proper to employ remedies directed against the condition. There are a few 
cases of trachoma with ulcerating pannus which require paracentesis of 
the cornea. In such cases there is intense pain. Paracentesis is followed 
by relief of pain and general improvement in the eye. If an ulcer of the 
cornea is about to perforate, paracentesis should be resorted to, the instru¬ 
ment passing through normal tissue, and not through the floor of the ulcer. 
The pannus of phlyctenular disease usually clears up under the local appli¬ 
cation of the yellow oxid ointment and the use of proper constitutional 
remedies. 

In pannus siccus good results sometimes follow massage with one of 
the mercurial ointments continued for a long period; but in many cases 
it will be necessary to use the irritant treatment by jequirity. A 5-per-cent, 
infusion of the seeds is brushed on to the eyelids and cornea, and the 
resulting conjunctivitis is intensified by repeating the application in twenty- 
four or forty-eight hours, as necessary. The remedy sets up an acute inflam- 


DISEASES OF THE CORNEA. 


329 


mation, with enlargement of the vessels in the cornea, swelling of the 
conjunctiva, and the production of a grayish membrane on the affected 
tissues. There is some constitutional disturbance and an increase of the 
temperature. The pre-auricular and cervical glands may be swollen. The 
subsidence of jequirity-ophthalmia is followed in many cases by a clearing 
of the cornea. The remedy is not without danger. Rules for its use have 
been formulated by Nuel as follows: (1) the pannus should be complete, 
since non-vascularized portions may perforate; (2) the cornea of the second 
eye should present more or less pannus, the result of a contagious conjunc¬ 
tivitis; and (3) the palpebral conjunctiva should show a granular or 
cicatricial condition with slight discharge. Where there is an abundant 
discharge the use of jequirity is unsafe, since it causes too severe a reaction. 
If these precautions are not observed, the jequirity i nfl ammation may pro¬ 
duce ulceration of the cornea with perforation and loss of the eye. In any 
event suppurative dacryocystitis is sometimes caused. 

In some cases of old rebellious pannus, where the cornea remains 
vascular after trachoma has been cured, the operation of periectomy, as 
described on page 301, is followed by improvement. 

Keratitis Bullosa (Pemphigus of the Cornea; Keratitis Vesiculosa).— 
This rare variety of vesicular corneal inflammation occurs chiefly in middle- 
aged or elderly persons. It may be found in eyes which previously have been 
normal, but more often it occurs in those which are affected with glaucoma, 
iridocyclitis, or corneal cicatrix. A few cases are due to trauma, such as 
abrasion of the cornea by the finger-nail. The characteristic feature of the 
disease is the formation of a large vesicle, or bulla, which involves the outer 
part of the corneal surface and is tremulous. After a few days the vesicle 
ruptures, and coincidently there is great pain. The anterior wall of the 
vesicle, consisting of the epithelial layer (sometimes the deeper layers) of 
the cornea, is not shed, but remains in situ. After a variable time it is lifted 
up by fluid, bursts again, and this process is often repeated for many weeks. 
Ciliary injection, photophobia, lacrimation, increased tension, and pain 
are prominent symptoms during the development of the vesicle. Often 
these symptoms subside after the vesicle bursts. Fuchs explains the origin 
of corneal bullae as follows: In glaucomatous eyes lymph-stasis causes an 
interstitial edema and results in lifting up the epithelial layer; if the fluid 
penetrates Bowman’s layer, the latter also is lifted up. 

Prognosis in bullous keratitis is unfavorable. During the height of 
the disease the eye is painful, and vision is much reduced or entirely lost. 
After recovery the cornea remains opaque. There seems to be no tendency 
to the involvement of the second eye. Under the most skillful treatment the 
disease will continue for weeks or months. 

Treatment should aim to relieve pain and irritation and reduce in¬ 
creased tension. The use of collyria of holocain and cocain gives only tem¬ 
porary relief. Removal of the anterior wall of the vesicle and the appli¬ 
cation of strong solutions of silver or burning with the galvanocautery may 


330 


MODERN OPHTHALMOLOGY. 


be followed by improvement. If the intra-ocular tension is increased and 
does not yield to arecolin or eserin, an iridectomy should be made. Atten¬ 
tion should be given to the general health. In some cases tonics and anti¬ 
septics can be \ised with benefit. If vision is lost, and recurring crops of 
vesicles make the patient miserable, enucleation for the relief of pain may 
be a justifiable operation. 

Aspergillar Keratitis (Keratomycosis Aspergillina) is a variety of 
corneal inflammation which is more common than would be supposed from 
the limited literature. Probably locality has much to do with its frequency, 
one country physician living near St. Louis having met with seven cases 
within two years. The only case of the disease which the author has seen 
came from the same vicinity. The disease begins with great pain in the eye, 
together with photophobia and lacrimation. After twenty-four or forty- 
eight hours a small black body is visible in the substance of the cornea. 



Fig. 230. —Microscopic section of growth in aspergillar keratitis. (Author.) 

(Original drawing by Da. Carl Risen.) 

1, Epithelium of the cornea. 2, Sporangia. 5, Mycelium. 4, Pus-corpuscles. 

The pain is constant and increasing, and is out of all proportion to that 
resulting from the lodgment of a foreign body in the cornea. After dis¬ 
secting the black body from the cornea the patient makes a rapid recovery. 
If the case is not treated early by removal of the small black body, the 
superficial layers of the cornea slough, leaving an ulcer which lasts until 
after the surgeon removes the aspergillar mass. This is of a black or dark- 
brown color, and may be mistaken for an ordinary foreign body. The mass 
is rounded and soft. Microscopic examination shows its nature. Failure 
to recognize the condition and remove the aspergillar mass may result in 
loss of the eye through corneal sloughing, perforation, and panophthal¬ 
mitis. In the few cases of keratomycosis aspergillina in which cultures have 
been made only Aspergillus fumigatus has been found. 

Wicherkiewicz saw a case of keratitis produced by Penicillium glaucum, 
and Wolfner met with one in which Mucor corymbifer was present. 



DISEASES OF THE CORNEA. 


331 


Malarial Keratitis (Dendritic Keratitis; Keratitis Dendritica Exul- 
cerans Mycotica).—Although in a strict pathologic sense it is incorrect to 
speak of a malarial keratitis, since the Plasmodium malarice cannot produce 
an acute inflammation, yet from a clinical point of view it is wise to retain 
the term. The disease is a superficial keratitis, attended by a dendritic ul¬ 
ceration, occurring in persons sick with malaria. It is found chiefly between 
the ages of twenty and fifty years, is more common in males than in females, 
and is seen more frequently in the summer and fall than in the winter and 
spring. The ocular disturbance, which is usually preceded by intermittent 
fever, begins with pain, photophobia, lacrimation, and the sensation of a 
foreign body in the conjunctiva. In some cases the disease begins with 
supra-orbital neuralgia. Within a few hours after the advent of these 
symptoms, numerous small, rounded, bead-like elevations are seen in the 
cornea; and a day later the elevated spots disappear, leaving superficial 
ulcerations of irregular shape (Fig. 5, Plate XI). The process extends, 
small, branching furrows running off from the initial lesion. The furrows 
are of a bluish-gray color. The ulcers do not penetrate deeper than Bow¬ 
man's layer. The cornea is anesthetic, tension is normal, and liypopj'on 



Fig. 231.—Malarial keratitis. (Kipp.) 


rarely occurs. Pain in and around the eye is severe and continues until the 
process of ulceration has been checked. Iritis is a rare complication. The 
duration of the disease varies from two or three weeks to as many months. 
The resulting opacities are not usually dense, but can be seen by oblique 
illumination many months after cure. Becurrence of the keratitis may 
appear with each recurring attack of malarial fever. 

Etiology. —Although Kipp and Hotz, who were among the first to 
recognize this disease, formerly held it to be pathognomonic of malaria, 
further observation has shown this view to be erroneous. Dendritic keratitis 
sometimes occurs in healthy persons. It has been observed in scrofulous 
and tubercular subjects. Kipp now believes that malaria is the cause of 
90 per cent, of cases of dendritic keratitis. Xoyes held that, while this 
peculiar form of keratitis could co-exist with malaria, it was essentially 
a mycotic disease. Knapp has seen superficial keratitis as a symptom of 
acquired syphilis. 

Prognosis. —The prognosis of dendritic keratitis is favorable. 

Treatment. —The use of atropin, of protective spectacles, and the 
occasional instillation of a 1-per-cent, strength solution of holocain, to 


332 


MODERN OPHTHALMOLOGY. 


relieve pain, will be advisable. If the disease extends, all of the furrows 
and their ramifications should be thoroughly scraped under local anesthesia 
and a solution of bichlorid of mercury (1 to 2000) should be used to flush 
the conjunctiva. This treatment usually checks the process, and the use of 
the galvanocautery will rarely be necessary. The general treatment is of 
great importance in these cases. Often the keratitis will prove rebellious 
to all local measures and will yield readily after a prolonged course of anti- 
malarial medication. 

Filamentary Keratitis.—This unusual condition, which may follow 
corneal wounds or vesicles, is characterized by the appearance of small 
globules attached to the cornea by a twisted pedicle or filament. These 



apparent vesicles are small, the largest having a diameter of 1 to 1.5 milli¬ 
metres. From time to time a new eruption appears, and thus the disease 
may continue for months or years. The disease, which occurs chiefly in 
persons of advanced age, produces the usual signs of keratitis. When exam¬ 
ined microscopically the filaments are seen to consist of granular masses 
attached by a rope of epithelium, thick at its corneal attachment and pointed 
at its extremity. The condition, which originates in the corneal epithelium 
(Hess), is likely to recur, successive crops of vesicles and filaments being 
produced. The disease sometimes occurs in chronic ulcers and in the kera¬ 
titis bullosa of absolute glaucoma (Hess). Filamentary keratitis may be 
confounded with herpetic keratitis. Removal of the filaments by curette- 
ment is followed by relief, but recurrences are frequent. In these cases the 



DISEASES OF THE CORNEA. 


333 


use of a 2-per-cent, strength solution of ammonium clilorid is said to be 
beneficial. 

Keratitis Punctata (Descemetitis; Aquo-capsulitis; Serous Iritis; 
Serous Cyclitis).—This affection, which by some writers is discussed under 
corneal diseases, will be considered in Chapter XI under the name “Serous 
Cyclitis,” because recent investigations have shown that it depends on 
alterations in the glands of the ciliary body. The characteristic feature of 
keratitis punctata is the presence, on the posterior surface of the cornea, 
of numerous dots of fibrin, which usually are disposed in the form of a 
triangle whose base is downward toward the corneoscleral junction (kera¬ 
titis 'punctata profunda). 

Bruns contends that there cannot be such a disease as serous iritis, 
since descemetitis (punctate keratitis), the symptom on which the diag- 



Fig. 233.—Keratitis punctata. (Author.) 

(Original drawing by Du. II. W. Mills.) 

nosis of serous iritis was long made to rest, is most frequently the principal 
symptom of acute plastic chorioiditis. In the absence of an ophthalmoscopic 
examination the chorioidal disease is overlooked. 

Superficial Punctate Keratitis (Keratitis Subepithelialis Centralis; 
Nummular Keratitis; Relapsing Herpes of the Cornea; Macular, or 
Nodular, Keratitis).—A form of punctate keratitis, located in the super¬ 
ficial layers of the cornea, and occurring in young subjects during an attack 
of acute catarrhal conjunctivitis, has been named keratitis punctata super - 
ficialis by Fuchs. The cornea presents minute gray dots, often arranged 
in groups or rows, scattered irregularly over the cornea or massed in the 
centre. They may be present coincident with the conjunctival inflam¬ 
mation or may follow it by days or weeks. The spots cause the epithelium 
to bulge and give the cornea a cloudy look. Often the spots remain un¬ 
changed for months and gradually disappear. Like heipes of the cornea, 


334 


MODERN OPHTHALMOLOGY. 


this disease sometimes develops simultaneously with an acute catarrhal 
inflammation of the respiratory tract, but it is distinguished from herpes 
by the absence of vesicles. The attack usually begins with symptoms of 
conjunctivitis, with profuse lacrimation, and with catarrh of the air- 
passages. In two or three days numerous gray or yellowish-green spots ap¬ 
pear beneath Bowman’s layer; the cornea becomes hazy, and often gray 
radiating lines are present. The spots, which are one millimetre or less in 
diameter, should be looked for with a magnifying glass. Loss of vision in 
this disease will be commensurate with the number and location of the spots. 
If they are numerous and occupy the pupillary area, vision will be much 
reduced. One or both eyes may be involved. Although some authors state 
that iritis and hypopyon never are seen in this affection, it will be well 
to bear in mind the possibility of their occurrence. 

Etiology. —As regards the etiology of this disease, Nuel has found it 
chiefly among subjects between twenty and thirty-five years of age, who had 
been exposed to intense cold. Microscopic study shows the disease to be due 
to an ill-identified coccus—according to Valude, the staphylococcus. 




A B 

Fig. 234.—Appearance of the cornea in punctate keratitis. (Knies.) 

A, Keratitis punctata superficialis (Fuchs). 11, Opacities found in parenchymatous keratitis. 

Pathology.— Xuel has found the edema of this disease to be located 
in the anterior corneal lamellae. The spots are due to filaments of fibrin 
undergoing a hyalin change; the filaments are disposed in spiral form and 
are situated between the corneal lamellae. They form the spots described 
above. At the level of these spots the corneal epithelium forms projections, 
which are converted into lacunae. Micrococci are found in the swollen epi¬ 
thelium. There is an absence of invasion by migratory cells. 

Prognosis. —The prognosis of this form of keratitis is favorable. Al¬ 
though the course of the disease may be prolonged, the spots gradually 
disappear by resorption. 

Treatment. —Irritants and astringents are out of order in this disease. 
Atropin, dark glasses, and attention to the general health will comprise the 
therapeutic measures to be used. If increased tension occurs, a paracentesis 
of the cornea should be made. 

Ribbon-shaped Corneal Opacity (Calcareous Keratitis; Primary, or 
Zonular, Opacity of the Cornea; Transverse Film of the Cornea; Keratitis 
Trophica; Keratite en Bandelette).—This unusual form of keratitis may 
be congenital or acquired. As a congenital condition it is of exceedingly 








DISEASES OF THE CORNEA. 


335 


rare occurrence. In the acquired form it is present in two distinct clinical 
types: In the one the interpalpebral part of the cornea, in eyes which 
were previously normal, becomes opaque, owing to the development of a 
smooth sub epithelial opacity. In the other type an oval transverse band 
of opacity develops in eyes which have long been blind from iridocyclitis, 
sympathetic ophthalmitis, or glaucoma. This form of opacity produces a 
roughening of the cornea and occurs chiefly in the lower third of the 
tunic. Since this is the part of the eye which is exposed when the globe 
is rolled upward, as in sleep, the condition has been thought to be due to 
imperfect closure of the lids during sleep or in the course of exhausting 
disease. 

In the first type the local change consists in a deposit of lime salts 
beneath the epithelium, which is unaffected. The opacity is sharply 
defined while the remaining cornea is clear. The opacity forms a gray area, 
three to five millimetres in width, passing across the cornea below the centre 
of the pupil. Often there is an oval opacity at the outer and another at the 
inner part of the cornea, separated from the limbus by clear corneal tissue. 



A B 


Fig. 235.—Appearance of the cornea in ribbon-shaped opacity. (Knies.) 
a, In an early stage. £, In a late stage. 

The two oval masses are connected by a bridge through which the pupil can 
be seen. 

Usually the process requires years for its development, but Poulett 
Wells has described a case of marked zonular opacity of the cornea which 
developed in a few months. Some authors have attributed these opacities 
to an excess of uric acid in the blood, while others think them due to external 
injurious influences. Fuchs saw transverse films in both eyes of a physician 
who for many years had blown calomel into them, and Topolanski met 
with the disease in hat-makers whose eyes were daily irritated by flying 
pieces of hair. 

A corneal disease, which is similar to ribbon-shaped opacity, is found 
among persons engaged in the manufacture of anilin dyes and of naphthalin. 
The long-continued irritation of the fumes produces a brown or gray su¬ 
perficial opacity of the cornea. The affected zone corresponds to the 
interpalpebral cleft. The opacity, which is located in the epithelial and 
superficial corneal layers, slowly disappears after the patient changes his 
occupation. 




336 


MODERN OPHTHALMOLOGY. 


The presence of transverse films is not incompatible with the pos¬ 
session of useful vision. Where vision is much reduced the films should 
be removed by scraping (abrasion) of the cornea. If the opacity is ex¬ 
tensive, iridectomy may be required. 

Herpes of the Cornea (Herpes Febrilis or Catarrhalis).—This disease, 
which is to be distinguished from herpes zoster ophthalmicus with corneal 
lesions, and other forms of corneal inflammation in which vesicles or bullae 
form, often occurs in connection with labial or nasal herpes. It is char¬ 
acterized by the development of numerous transparent vesicles, one-half to 
one millimetre in diameter, scattered over the cornea or grouped at the 
periphery in such a manner as to form an irregular, fork-shaped line. 
The vesicles, for the most part, contain simply a serous fluid devoid of 
lymph-cells. The vesicles burst at such an early period in the history of 
the case that generally, when a surgeon is called, only an irregular corneal 
ulcer is to be seen. Unlike phlyctenular keratitis, herpes of the cornea is 
unaccompanied by abnormal vascularity, and ordinarily is limited to one 
eye. The anterior wall of the vesicles is formed of epithelium and Bowman’s 
layer, and the base is composed of the substantia propria. Thus it is seen 
that the process is deeper than is that of phlyctenular keratitis. The disease 
is more common in middle and advanced life than in childhood. 

Symptoms. —The subjective symptoms are those of a foreign bod 3 r in 
the eye. Lacrimation and photophobia are severe until after the bursting 
of the vesicles. In many cases the corneal lesions are seen coincidently with 
affections of the respiratory tract, such as rhinitis, bronchitis, pneumonia, 
and pertussis. Herpes has been seen also in patients with intermittent and 
typhoid fevers. Herpes of the cornea, unconnected with any other disease, 
sometimes occurs, and such cases show frequent relapses. Hew vesicles may 
appear periodically. There is likely to be severe frontal, temporal, and 
supra-orbital neuralgia ; the upper lid may be red and swollen, and the 
bulbar conjunctiva injected. Inspection shows an irregular loss of corneal 
epithelium, presenting a “string of beads” appearance, due to shreds of the 
broken vesicle-walls; the surface of the ulcer is anesthetic. The disease 
may be complicated with hypopyon and iritis. Catarrhal conjunctivitis may 
also be present; intra-ocular tension is usually diminished. The corneal 
lesions may heal in ten days or two weeks under favorable circumstances; 
some cases, however, are attended by secondary infection and are of long 
duration. The slight nebulas resulting from herpes generally clear in a 
few weeks. In mild cases the vesicles may flatten and disappear without 
bursting. 

Treatment. —This will depend on the stage of the disease. If seen 
before the vesicles have burst, the eye should be bandaged, and atropin and 
holocain can be used cautiously to relieve pain and photophobia. Yon 
Graefe advised that the vesicles be ruptured by dusting calomel upon the 
eye; and Swanzy accomplishes the same result by brushing the cornea 
with a cameFs-hair pencil wet with an antiseptic solution. 


DISEASES OF THE CORNEA. 


337 


In the period of repair the frequent use of hot water and the local 
application of an ointment of ammoniated mercury or yellow oxid, or the 
insufflation of a powder of boric acid or aristol will be in order. The appli¬ 
cation of tincture of iodin has been recommended. In rebellious cases 
recourse can be had to a mild use of the galvanocautery. The internal treat¬ 
ment is of importance. The respiratory organs should be given the neces¬ 
sary attention. In cases characterized by periodic recurrences the use of 
a saline purge, followed by quinin and tonics, will be of value. 

Marginal Keratitis (Keratitis TJlcerativa Marginalis).—Ulceration of 
the cornea occurring at the corneoscleral margin may assume several forms. 
Under the name keratitis ulcerativa marginalis, W. A. Martin, of San 
Francisco, has described cases of acute corneal disease occurring in adults and 
characterized by the following features: The initial symptoms are peri¬ 
corneal injection and photophobia, followed by the development of a row 
of papillae in the cornea about the line of the arcus senilis. These papillae 
become confluent, break down, and form a line of narrow ulcers which may 


§ § 


A B 

Fig. 236.—Appearance of the cornea in herpes febrilis. (Knies.) 

A, Early stage of herpes. B, The same eye four days later. 

almost encircle the cornea. Separating the ulcerated spots from the limbus 
is a zone of transparent corneal tissue. The disease does not encroach upon 
the centre of the cornea. Under proper treatment healing occurs rapidly. 
In some cases, as soon as the ulcerated spots heal, others occur farther on, 
until the whole cornea has been traversed. Under daily use of a mild 
bichlorid solution and calomel insufflations healing occurs without scarring. 
Unlike the catarrhal ulcers described by Fuchs, keratitis ulcerativa mar¬ 
ginalis is a primary disease. 

A different type of marginal keratitis is that of Fuchs: keratitis mar¬ 
ginalis profunda , which belongs to the class of parenchymatous or inter¬ 
stitial corneal inflammations. Here the process is a chronic one, and the 
transparent zone adjoining the corneoscleral junction is obliterated. It is 
a rare disease, occurring in old people and usually is limited to one eye. 
Grayish or yellowish-gray opacities, forming at the periphery, project into 
the cornea for two to three millimetres. The opaque zone involves gen¬ 
erally one-third to one-half of the circumference. Irritative symptoms dis¬ 
appear in ten to fourteen days, but a permanent gray opacity remains and 




338 


MODERN OPHTHALMOLOGY. 


resembles arcus senilis. It is distinguished from the latter by the absence 
of a zone of clear corneal tissue. Owing to the location of the lesions in 
this disease, no damage is done to vision. 

Treatment.— In the treatment of marginal keratitis the surgeon is 
to be guided by general principles and common-sense. Atropin and holo- 
cain are to be used cautiously to relieve pain and photophobia, and a 
bichlorid solution is to be applied two or three times daily. If pain is vio¬ 
lent, use can be made of dionin and cocain (dionin, gr. ij; cocain, gr. ij; 
water, oiv. M. Sig.: One drop in the affected eye five or six times a day). 
Insufflations of calomel are valuable in marginal ulcers. If the ulcer ex¬ 
tends in depth it will be necessary to apply the curette or electrocautery, 
while eserin or arec-olin is used to contract the pupil. 

Striped Keratitis (Striate Keratitis).—This name has been applied to 
two different conditions which occasionally occur after cataract extraction 
or trauma. In both there is an opacity which is located in the posterior 
layers of the cornea. In true striped keratitis there is noticed, at the first 



Fig. 237.-—Section of the cornea in striate keratitis. (Hess.) 

The folding of the posterior layers of the cornea is shown in the lower part of the figure. 

or second dressing after cataract extraction, the presence of fine straight 
lines of opacity, one-half to one millimetre in width, which converge toward 
the wound. In some cases the lines cross, forming panel figures. Several 
theories have been advanced to account for the phenomenon. Beck and 
Recklinghausen attributed it to dilation of lymph-spaces; Alt, to infiltra¬ 
tion of large nerve-canals; but the view now generally accepted is that of 
Carl Hess and others, viz.: that this peculiar striate opacity depends on the 
folding of Descemet’s membrane, resulting either from the shrinking of the 
cornea by cicatrization or from unequal swelling of the corneal tissue by 
infiltration. However produced, the condition generally disappears within 
a few days. Striped keratitis is occasionally seen after corneal injuries or 
inflammation. 

The other type of opacity, which is common after cataract extraction, 
is in the form of permanent white opacities, which are due to the action 
of chemicals. It is often seen in the practice of those surgeons who irrigate 
the anterior chamber with solutions of bichlorid of mercury. These opaque 
spots materially reduce vision and cannot be removed. 




DISEASES OF THE CORNEA. 


339 


Disc-like Keratitis (Keratitis Disciformis).—A type of keratitis, which 
somewhat resembles ulcus serpens, is known as keratitis disciformis. It is 
characterized by the development, in the middle layers of the cornea, of a 
gray, discoid opacity. The disc is separated from the transparent peripheral 
portion of the cornea by a grayish border. In the middle of the disc is 
generally a small spot of deep infiltration. Surrounding this spot are 
curvilinear lines. Disciform keratitis does not become yellow and does not 
lead to corneal necrosis. It is only in exceptional cases that it leads to a 
loss of substance in a circumscribed area. Inflammatory symptoms are not 
marked. Hypopyon is either absent or is of small extent. The superficial 
corneal layers are generally unaffected, but, in the course of the disease, 
small ulcers may appear. This type of corneal inflammation generally lasts 
several months and leaves a cloud. Fuchs attributes it to the infection 
which follows a small epithelial lesion, and which is not sufficiently virulent 
to cause a serpiginous ulcer. Disc-like keratitis is to be distinguished from 
the deep and from the annular forms of corneal inflammation. Atropin 
locally and proper internal medication will comprise the treatment of this 
disease. 

Grill-like Keratitis (Gitterformige Keratitis; Keratite Quadrillee) has 

been described by Haab. The cornea presents a central opacity which, by 
transmitted light, shows forked lines with points scattered through them, 
the wdiole resembling latticework. Darier believes that it is due to an infil¬ 
tration of leucocytes into the corneal spaces. He states that the disease 
improves rapidly under subconjunctival injections of sodium chlorid or 
under instillations of dionin. 


MISCELLANEOUS DISEASES OF THE CORNEA. 

Discoloration of the Cornea with Blood-pigment (Blood-staining of the 
Cornea).—This rare condition, which involves some difficult points in diag¬ 
nosis, has been studied by Vossius, Treacher Collins, Lawford, Weeks, 
Griffith, and others. In a case of blood-staining of the cornea there is first 
a blood-clot in the anterior chamber, due usually to trauma or operation, 
although the hemorrhage may have occurred spontaneously in old cases of 
retinal detachment. In nine of seventeen cases mentioned by Collins the 
tension was increased; in six others it was normal or minus. The phe¬ 
nomenon may occur at any age. In the author’s case, a man, aged 35 years, 
was struck on the right eye by a piece of steel. One month later an opera¬ 
tion (probably an iridectomy) was immediately followed by hemorrhage into 
the anterior chamber and blood-staining of the cornea. Two years later the 
appearance of the eye was that represented in Fig. 3, Plate XI. The 
entire cornea was of a brick-dust color. In most of the cases heretofore 
reported a narrow peripheral ring, one to one and one-half millimetres wide, 
has remained clear and uncolored. This condition may be mistaken for 
an anterior dislocation of the lens. As regards the nature of the pigment 


340 


MODERN OPHTHALMOLOGY. 


which is distributed through the cornea, the microspectroscopic and chemic 
examinations of Collins show that the discoloration is due mainly to crystals 
of hematoidin, with or without hemosiderin, which enter the cornea in 
solution in blood diffused through Descemet’s membrane. After a period 
varying from two to many years, the discoloration disappears, the periphery 
being the first to clear. Treatment of this condition seems to be useless, 
although alteratives may be tried. 

As regards diagnosis, it will be necessary to distinguish between hem¬ 
orrhage into the anterior chamber, forward dislocation of the lens, and 
blood-staining of the cornea. When the whole cornea is stained it cannot 
be distinguished from distension of the anterior chamber with blood, but 
if the peripheral clear zone is present, the distinction can be made. When 
the central part of the cornea is of a rusty-brown color frpm blood-staining, 
and the periphery is clear, the condition so much resembles that of an 



The eye was glaucomatous, which accounts for the adhesion of the iris to the posterior 
surface of the cornea. Numerous blood-vessels are present in the atrophic and sclerosed 
limbus. 

amber-colored lens, dislocated forward, that the best observers have been in 
doubt. It would seem that focal illumination ought to be of value in making 
the diagnosis. In the author’s case focal illumination showed clearly the 
presence of wavy reddish lines in the cornea. Probably these were dis¬ 
tended lymph-channels. 

Sclerosis and Atrophy of the Limbus.—Fuchs has recently described 
a rare condition in which a groove-like depression circumscribes the periph¬ 
ery of the cornea without the occurrence of ulceration. The disease, which 
is found chiefly in elderly persons, is a senile change ingrafted upon a con¬ 
comitant arcus senilis. There is a hyalin deposit in the superficial corneal 
layers. Some of the hyalin masses may be visible in the living eye, exam¬ 
ined under a loupe, appearing as whitish points. Ectasia of the cornea has 
been present in some of these cases. There is no known treatment for the 
condition. 





DISEASES OF THE CORNEA. 


341 


Siderosis of the Cornea.—In this condition opaque spots of a rust- 
brown color form in the cornea. The author has observed one such case of 
corneal staining due to the lodgment of a piece of steel in the lens. 

Xanthelasma of the Cornea.—This is a degeneration of the cornea 
and is characterized by its yellow color. It follows injuries attended with 
shrinking of the globe and often exists with a calcareous deposit in the 
cornea. Such eyes are usually sightless. They are prone to occasional 
attacks of inflammation and may be the cause of sympathetic ophthal¬ 
mitis. There is no particular treatment for the condition. If indicated, 
an enucleation or a Mules operation should be performed. 

Tuberculosis of the Cornea.—The cornea, like the lens, is much less 
liable to tuberculosis than are the other ocular structures. The disease may 
be primary or secondary to tuberculosis of the conjunctiva or iris. Panas 
has recorded a case of primary corneal tuberculosis in a woman of 30 years, 
who had severe pain in the right eye and presented diffuse interstitial 
opacity of the upper segment of the cornea. Two weeks later the centre 
of the cornea showed yellowish nodules resembling miliary tubercles. These 
coalesced and formed an ulcer with yellow base and irregular margins. 
Eugene Smith, of Detroit, has observed a case of primary corneal tuber¬ 
culosis. Three tubercular foci were present in the posterior part of the 
substantia propria without ulceration of the cornea and without implication 
of Descemet’s membrane. 

The diagnosis of corneal tuberculosis rests on the finding of tubercle 
bacilli in scrapings from the cornea. The treatment is the application of 
the electrocautery. 

Lepra of the Cornea.—Keratitis occurring in lepers is not specific, but 
is generally due to traumatism. Ulceration, which is most frequent in the 
lower limbus, is rarely deep or acutely septic and generally heals under mild 
treatment with temporary closure of the eyelids. The infiltration in lepra 
of the cornea begins peripherally. There may be a small dotted, yellowish 
deposit; or there may be a distinct nodule involving the cornea, sclerotic, 
and iris simultaneously. Both eyes may be symmetrically involved. The 
infiltration consists partly of bacilli, but chiefly of cells in a brown state of 
granular degeneration (Neve). The process may extend and involve the 
iris and deeper ocular structures. 


PROTRUSIONS OF THE CORNEA. 

Protrusions of the cornea comprise staphyloma, kerectasia, keratoconus, 
and keratoglobus. The first and second of these originate in inflammatory, 
and the third and fourth in non-inflammatory processes. 

Staphyloma of the Cornea.—This is a condition in which a corneal 
scar with adherent iris bulges outward (Fig. 4, Plate XI). It is total when 
the entire cornea is involved, partial when only a part is concerned, or 
racemose when perforation of the cornea has occurred at several points. 


342 


MODERN OPHTHALMOLOGY. 


Staphyloma may have a spheric or a conic shape. It may be limited to the 
cornea or involve also the ciliary region. The alteration is brought about 
by intra-ocular pressure acting on a tissue which is softened by inflamma¬ 
tory action. Intra-ocular pressure in staphyloma is increased in one of two 
ways: if, as often happens, the iris is fastened to the posterior corneal sur¬ 
face, the anterior chamber is abolished and increased tension occurs from 
closure of the drainage outlet; in other cases it is assumed that, as the 
staphyloma increases, tension on the adherent iris causes irritation of the 
ciliary glands with increased secretion of the aqueous humor. Having at¬ 
tained a certain size, a staphyloma may remain stationary or it may further 
extend and rupture. The rupture closes only to reopen when tension rises. 
After repeated ruptures infection may take place and the eye may be lost by 
panophthalmitis. Although staphyloma may follow corneal inflammation, 
or may be present as a congenital condition without perforation, it is the rule 
that it follows perforation with iris-prolapse. If an iris-prolapse heals with 
the formation of a flat cicatrix, the result is favorable to the integrity of the 



Fig. 239.—Staphyloma of the cornea. (Author.) 

globe, although vision is much reduced; but if the protruding iris becomes 
covered with cicatricial tissue, which is too weak to resist intra-ocular pres¬ 
sure, the ectatic cicatrix forms a staphyloma. If the whole cornea is in¬ 
volved in the ectasia, we speak of total staphyloma; if only a part bulges, the 
staphyloma is partial. If all the corneal layers down to the posterior elastic 
lamina are destroyed, and this protrudes as a small bladder, the name Icerato- 
cele is applied to the condition. After a corneal wound, or following upon a 
perforating ulcer, a minute opening may remain for a considerable time; 
or a keratocele may break from time to time. In either event the term 
fistula of the cornea is used to describe the condition. When a large part 
of the cornea is destroyed, the exposed area is covered with a transparent 
layer of lymph, which deludes the patient into the belief that he will retain 
useful vision. Soon, however, the new tissue becomes opaque, and vision 
is reduced to quantitative perception of light. 

Symptoms. —Early in the history of staphyloma pain, photophobia, 
lacrimation, and redness are present. The opaque cornea is seen to bulge. 



DISEASES OF THE CORNEA. 


343 


Gradually the inflammatory symptoms subside and the staphyloma appears 
as a protruding mass, which may be so extensive as not to be covered by 
the eyelids. In this event the apex becomes irritated, or it may become 
dry and resemble skin. A corneal staphyloma forms an opaque mass of 
whitish, bluish, grayish color, traversed by a few large vessels. Often in 
old cases there is a calcareous deposit in the apex of the mass. Hyalin 
degeneration is not uncommon in old cases, and keloid sometimes grows 
from a thickened staphylomatous cornea. If the protruding cornea is thin 
and translucent,— i.e., the process is of recent date,—it will be possible 
to discern the outlines of the iris. Tension in old staphylomata may be 
normal, but, whether normal or increased, it leads sooner or later to rupture 
of the staphyloma or to excavation of the nerve-head. The tendency of a 
corneal protrusion is to become large and involve the entire globe, leading 
to general distension of the eyeball. Vision may be retained sufficiently 
to permit the patient to count fingers and find his way about, but usually 
it is limited to perception of light. Suppurative inflammation may occur, 
owing to exposure of the protruding mass to the irritating effects of air 
and dust. In such a case there will be great pain and marked inflammatory 
symptoms. In quiet staphylomata there is often considerable pain from 
.pressure of scar-tissue upon nerve-filaments or from the presence of irido¬ 
cyclitis. 

Diagnosis. —Staphyloma can be distinguished from corneal opacities 
by the presence of the protrusion. New growths appearing on the cornea 
and springing from the corneoscleral region externally, or intra-ocular 
tumors which have broken through the ocular shell, may cause the inex¬ 
perienced observer to be in doubt, but the history of the case and close 
attention to the appearance of the eye will clear the diagnosis. 

Prognosis. —Corneal staphyloma must always be regarded as a serious 
condition. Its prevention is of greater importance than its treatment. 

Treatment. —The prevention of staphyloma concerns the proper treat¬ 
ment of iris-prolapse. To secure the production of a flat scar is of the ut¬ 
most importance in cases of iris-prolapse (see page 316). When this result 
has been attained, means should be employed to prevent bulging of the scar. 
They include the use of such measures as the compress bandage, the appli¬ 
cation of a mild miotic, and in suitable cases the operation of iridectomy— 
all for the purpose of reducing or limiting the effect of intra-ocular tension 
upon a softened tissue. Kuchler, in hopeless cases of sloughing cornea, with 
protrusion of iris and cicatricial tissue, in order to prevent staphyloma, 
passed a cataract-knife horizontally through the cornea, opened the capsule, 
and delivered the lens. This operation prevents staphyloma, leaves the 
globe of normal size, and does not increase the danger of panophthalmitis. 

Conspicuous staphylomata that cause loss of useful vision require 
enucleation of the eye, or, preferably, a Mules or Hall operation. Ex¬ 
cision of the staphyloma—an operation much practiced by de Wecker, 
Critchett, and others of the older ophthalmologists—is not to be consid- 


344 


MODERN OPHTHALMOLOGY. 


ered, since such a procedure not rarely results in sympathetic ophthalmitis 
or causes panophthalmitis. Particularly dangerous is Critchett’s operation, 
in which needles are passed through the base of the staphyloma to prevent 
loss of the vitreous humor. 

Keratoconus (Conic Cornea; Staphyloma Pellucidum).—In this con¬ 
dition the curvature of the cornea is changed from an ellipsoid to an 
hyperboloid of revolution. It is due to a disturbance between the resisting 
power of the cornea and intra-ocular tension, and ordinarily appears at or 
about the time of puberty, but may be congenital. Generally both eyes are 
affected. It is more frequent in females than in males. The apex, which 
is usually transparent, may show an opaque area. The protrusion may be 
slight or marked. In the former case the diagnosis of keratoconus will 



Fig. 240.-—Keratoconus. (Author.) 

(.Original drawing by Dn. R. W. Mills.) 


rest on the skiascopic test, which shows a triangular area of light, the base 
of the triangle resting on the margin of the iris and the apex corresponding 
to the apex of the corneal cone. The ophthalmometer can be used satis¬ 
factorily in the diagnosis of keratoconus. The mires are much distorted. 
That the deformity is not due to old corneal lesions can be shown by the 
absence of nebulas. If Placido’s disc is used in keratoconus, the circles are 
distorted. To the ophthalmoscope the details of the fundus are distorted, 
and a circle-shaped shadow is present. These effects are due to the high 
degree of corneal astigmatism produced by the projection. In marked cases 
of keratoconus the diagnosis can be made without instrumental aid by 
placing the patient alongside a window and viewing the cornea laterally. 

The subjective symptoms of keratoconus include near-sight, polvopia, 
and an indefinite uncomfortable sensation in the eyes and head. Inflam- 


DISEASES OF THE CORNEA. 


34.5 


matory symptoms are usually absent. Eelief is sought for defective vision, 
which often is reduced to one-thirtieth or one-fiftieth of the normal. Con¬ 
cave glasses give some improvement for a time. Clear vision cannot be 
obtained by concave spheres, since the cornea is not spheric, but conic. If 
the apex of the cone becomes infiltrated, vision is made much worse. 

Pathology.— The pathology of conic cornea is not understood. It is 
supposed to depend on a diseased condition of the uveal tract. 

Prognosis. —The prognosis will depend on the condition at the time 
the patient applies for treatment. If the apex of the cone is clear, the 
prognosis may be considered to be favorable. In some cases the protrusion 
stops at a certain point. 

Treatment. —In the early stages of conic cornea, when the disease 
is progressive, as is manifested by pain in and around the eye, the prolonged 
use of a mydriatic and bandage will be beneficial. Some surgeons, while 
continuing the use of the bandage, alternate mydriatics and miotics. After 
headaches and tenderness of the globe have disappeared, the refraction is 



Fig. 241.—Keratoglobus. (After Demours.) 

to be corrected. Here crossed cylinders will often be beneficial. Eaehlmann 
proposed to correct these cases by hyperboloid lenses made in Eathenow, 
but these have been discarded, because their use is limited. They are of 
value when their apices coincide with those of the corneal cones, and this 
obtains in only one position of the eye. Stenopaic spectacles are sometimes 
of benefit in cases of keratoconus, and are used by Snellen. 

The surgical treatment of conic cornea includes many procedures, of 
which the most valuable is the careful use of the galvanocautery, as is 
explained in the latter part of this chapter. 

Keratoglobus (Cornea Globosa; Megalocornea).—By the older authors 
hydrophthalmos was confounded with keratoglobus, but Horner, Pfliiger, 
and others have shown that the latter disease has nothing in common with 
buplithalmos. In keratoglobus the cornea presents a globular form, and is 
enlarged and clear. The iris also is enlarged. In two cases seen by Fick the 
eyes were hypermetropic, and in each visual acuity, tension, and fundus 
were normal. The affection is usually bilateral, and is not amenable to 
treatment. 


346 


MODERN OPHTHALMOLOGY. 


Keratectasia (Keratocele).—This is the name applied to a bulging 
forward of the deeper corneal layers, without perforation and without 
involvement of the iris. The condition is made possible by ulceration 
of a cornea which is distended by intra-ocular pressure. In rare in¬ 
stances it is sequent to recurrent attacks of marginal keratitis. Keratec¬ 
tasia is usually partial in extent and irregular in form, but sometimes it is 
regular and occupies the whole cornea. The latter cases usually are due 
to pannus of the substantia propria or to parenchymatous keratitis with 
softening of the cornea. If the cornea is ulcerated down to the membrane 
of Descemet, this layer is pushed forward in the form of a hernia through 
the perforation and the condition is termed keratocele. It appears as a 
transparent vesicle surrounded by an opaque cicatricial ring. Keratectasia 
is usually distinguishable from keratoconus and keratoglobus by the fact that 
the bulging portion of the cornea is opaque. A few cases of corneal ectasia 
have been observed following marginal keratitis, in which the ectasia was 
composed of apparently normal corneal tissue. 

Prognosis.— The prognosis in keratectasia is unfavorable. If the con¬ 
dition is detected early and is checked by treatment, much damage is done to 
vision, owing to the opacity and the irregular bulging of the cornea. In 
fully developed keratectasia treatment is powerless. 

Treatment. —In the formative stage repeated punctures of the cornea 
with a cataract-knife or small keratome should be practiced. The evacua¬ 
tion of aqueous humor is followed by temporary decrease in intra-ocular 
tension. This treatment should be followed by the application of a com¬ 
press bandage. After the process has reached maturity, if the keratectasia 
is small, it can be destroyed by the galvanocautery or punctured with a 
keratome, and in its place a flat cicatrix will form. Here also the compress 
bandage will be of value. The obstacles to excision of the affected area and 
the grafting therein of part of the cornea of one of the lower animals are at 
present so great as to make this operation of doubtful utility. 

Fistula of the Cornea (Fistulous Staphyloma).—This name is applied 
to two conditions. A true corneal fistula exists when, after a perforating 
wound or ulcer, a prolapse of iris occurs which is not large enough to close 
the tubular opening. Although the lens comes forward after the escape 
of aqueous humor and temporarily blocks the opening, healing does not 
occur, because a piece of the iris lies in the wound. In true corneal fistula 
there is a downgrowth of epithelium which also interferes with the healing 
process. 

A spurious fistula exists when a small corneal staphyloma repeatedly 
ruptures under the influence of intra-ocular pressure of either normal or 
increased amount. Microscopic examination shows an absence of epithelial 
downgrowth. The iris may or may not be incarcerated in the wound. In 
a case of this kind following a corneal ulcer, occurring in the author’s 
clinic, the patient was in the habit of opening the apex of the small 
staphyloma with a needle, whenever increased intra-ocular tension produced 


DISEASES OF THE CORNEA. 


347 


pain in the eye. The evacuation of aqueous humor was followed by several 
days of relief. As usually happens in corneal fistula, the case ended in an 
enucleation. Histologic examination showed an absence of epithelial lining. 

These definitions are based on pathologic studies. To distinguish the 
conditions clinically is often impossible. 

Clinically, a fistula of the cornea exists as a weak spot which alternates 
between closure and patency. Its site is indicated by the presence of a 
small, black point from which the aqueous humor seeps. When located 
near the centre of the cornea, the black point is absent and the area sur¬ 
rounding the fistula is composed of scar-tissue. 

A corneal fistula may follow a wound or be a sequel of ulcerative kera¬ 
titis. It may be located in any part of the cornea. When the cicatrix 
breaks, the aqueous humor is lost; the lens comes forward and may touch 
the borders of the fistula, causing an anterior polar opacity. The eye be¬ 
comes soft and may eventually be lost by infection or by atrophy of the globe; 
or the closing of the fistula may be followed by glaucomatous symptoms. 



Fig. 242.—Fistulous ulcer of the cornea. (Wurdemann.) 

Prognosis. —In brief, the prognosis of corneal fistula is unfavorable, 
the ejT, as a rule, being destroyed by chronic iridocyclitis, by panophthal¬ 
mitis, or by secondary glaucoma. 

Treatment. —This admits naturally of division into (1) medical or 
non-operative and (2) surgical treatment. 

1. The non-operative measures include rest in bed and the use of 
miotics (proposed by Zehender in 1808), for the purpose of reducing intra¬ 
ocular tension, and the application of a compress bandage to give support 
to the weakened tissues. Under this plan there is often an improvement. 
The anterior chamber re-forms and the surgeon may expect a cure. Often 
he will be disappointed. The intra-ocular tension rises, the weakened tissues 
rupture again, and the anterior chamber is abolished. Thus, the eye alter¬ 
nates between a condition of abnormal softness, due to an open fistula, and 
a state of gradual increase of intra-ocular pressure until rupture occurs. 
Such eyes often pass into a condition of chronic iridocyclitis with softening, 
or they may show panophthalmitis. As a rule, non-operative treatment is 







348 


MODERN OPHTHALMOLOGY. 


of value only in so far as it favors the restoration of the anterior chamber 
and renders the performance of iridectomy possible. The miotic to be 
employed should be arecolin, which is less irritating than eserin or pilo- 
carpin. It is to be employed in a 1 / 2 - to 1-per-cent, strength solution, 2 or 
3 drops being instilled into the conjunctival sac twice or thrice a day. If, 
under the use of the miotic and the bandage, the condition improves, noth¬ 
ing further will be necessary. If, however, the weakened cornea again 
breaks, as frequently occurs, only surgical measures can be looked to. 

2. Surgical ‘measures for the cure of corneal fistula are numerous. 
They include iridectomy, electrolysis, cauterization of the diseased area, 
covering it with a conjunctival flap, excision, bruising of the walls of the 
fistula with forceps, and the introduction of a suture. 



Fig. 243.—True corneal fistula, showing downgrowth of 
epithelium. (Author.) 

(Photomicrograph by Dr. II. P. Wells of a section lent by Du. W. E. Fischer.) 


Iridectomy will save some cases of fistula. It acts advantageously in 
two ways: (1) by reducing intra-ocular tension and (2) by removing a tag 
of incarcerated iris-tissue which prevents healing. To be of value in the 
latter instance it must be performed early, since iris-tissue which is in¬ 
carcerated in the lips of the corneal wound soon undergoes changes, be¬ 
coming intimately united with fibrin and exudates. 

Cauterization, theoretically, should be the ideal operation. It cer¬ 
tainly is a rational procedure to destroy the epithelium which has down- 
grown into the cornea and prevents healing. In the case of a spurious 
fistula— i.e., a small bulging scar—it is equally rational to use the cautery. 
But, unfortunately, by the methods heretofore in use, a thorough cauter¬ 
ization of the fistulous area cannot be accomplished without injury to the 




DISEASES OF THE CORNEA. 


349 


crystalline lens. Tims, the surgeon is likely to produce a cataract by at¬ 
tempting to cure a fistula. The depth of the normal anterior chamber is 
only 2.6 millimetres and, as stated above, the chamber is temporarily abol¬ 
ished whenever a corneal fistula is open. To obviate the dangers, and at 
the same time to obtain the benefits of cauterization, the author has devised 
the operation which is described in the latter part of this chapter. Excision 
and suturing have been proposed. They must be regarded as dangerous 
and unnecessary procedures. Many years ago de Wecker, believing fistula 
to be caused by the eversion of the membrane, of Descemet, devised the fol¬ 
lowing operation: A fine straight forceps was introduced. The wall of the 
fistulous tract was seized and torn so as to denude the true corneal tissue. 
A solution of atropin was used and a compress bandage was applied, being 
removed and reapplied daily for two weeks. In this way de Wecker cured a 
case which for ten months had resisted other methods of treatment. Hey- 
mann states that in some cases a permanent cure has followed the covering 
over of the fistulous area with a conjunctival flap. It is assumed that this 
procedure is preceded by a bruising of the walls of the canal and a removal 
of the tag of incarcerated iris. 

Electrolysis has been employed by Cornwall, who cured a case of 
corneal fistula in which an unfavorable prognosis had been given. The 
opening was situated near the corneal periphery and was so small that nearly 
normal tension was maintained. His procedure was as follows: The point 
of a jeweler’s broach was bent at a right angle to the main shaft, the bent 
portion measuring about one millimetre in length. Under cocain anesthesia 
this was inserted into the fistula. The dispersing electrode was placed on 
the cheek. A current of the strength of 1 / 4 milliampere was used. The 
bent portion of the electrode was rotated so as to describe a circle, and in 
this way the cornea and iris were eroded. The eye was bandaged for two 
days. A complete cure followed. 

OPACITIES OF THE CORNEA. 

In this place will be considered those opacities of the cornea which 
are stationary, reference having been made elsewhere in this chapter to 
the various changeable opacities which accompany keratitis. A stationary 
opacity, which is usually permanent, may be of inflammatory or of non¬ 
inflammatory origin. A typical example of the latter is the arcus senilis. 

Arcus Senilis (Gerontoxon Corneae).—This is an opaque circle situated 
within the corneoscleral margin, from which it is separated by a narrow 
strip of transparent cornea. It is due to hyalin degeneration, and is found 
chiefly in middle-aged and elderly subjects, although it has been seen in 
children. It is hereditary in some families. It appears first as a gray, 
semilunar arc in the upper part of the cornea; this is followed by a similar 
arc below, and finally the arcs unite to form a ring. The formation of 
arcus senilis must be regarded as physiologic in old people. The condition 


350 


MODERN OPHTHALMOLOGY. 


doc? not call for treatment and wounds through this part of the cornea—- 
for example, the incision for cataract extraction—heal kindly. 

Opacities due to Keratitis.—A faint opacity of the cornea which is 
visible only to careful (oblique) examination is known as a nebula; an 
’opacity which appears grayish by daylight is called a macula; and an 
opacity which causes disfigurement by its whiteness and density is named 
leucoma. If an adhesion of the iris to the cornea exists, the last-named 
opacity is called an adherent leucoma. All of these opacities reduce vision, 
and some cause positive disfigurement. 

The amount of reduction in visual acuity will depend on the density 
of the opacity, its location with reference to the pupil, and the amount of 
distortion of the corneal surface. In these cases vision for distance is much 
more reduced than is near vision. The opacity produces an irregular astig¬ 
matism, which often does not admit of improvement under glasses or the 
use of a stenopaic slit; and, furthermore, it is a fruitful source of nystag¬ 
mus, strabismus, myopia, and amblyopia. An adherent leucoma may pro¬ 
duce secondary glaucoma. Small corneal cicatrices sometimes cause kera- 
talgia, which is evidenced by lacrimation, pericorneal injection, and ciliary 
pain due to strangulation of nerve-filaments. Corneal scars may undergo 
hyalin, fatty, or keloid degeneration. Often the hyalin substance becomes 
impregnated with lime salts, as can be demonstrated microscopically. In¬ 
crustations of metallic salts are visible to the naked eye, and often follow 
the use of solutions of the acetate of lead in ulcerative keratitis. The result 
is a white scar. As has been said elsewhere, the salts of lead should never 
be used in the treatment of ulcer of the cornea. In some instances it seems 
impossible to demonstrate the presence of lead in corneal scrapings, but 
recently Ellett has found the usual lead reactions in microchemic examina¬ 
tion. 

Treatment. — Many remedies have been tried in the treatment of 
corneal opacities. Mercurial salves have been used, followed by massage 
of the eye through the lids. Calomel and other powders have been dusted 
on to the cornea, lotions have been sprayed on to the cornea, and jequirity 
has been brushed upon the conjunctiva, all with the purpose in view of 
causing irritation, stimulation, and absorption of the scar-tissue. Electric¬ 
ity has its advocates. Alleman favors the galvanic current; the cathode 
in the form of a silver cup, seven millimetres in diameter, in which a drop of 
mercury is placed, is applied to the cornea, while the anode of sponge is 
placed on the cheek. At first the seances last one minute and from 7* to 
1 1 / 2 milliamperes are used; later they last four or five minutes, and 3 or 
4 milliamperes are used. It is said that the greatest improvement obtains 
in the scar-tissue following interstitial keratitis, although opacities follow¬ 
ing corneal nlcers are also benefited. The treatment is given under holocain 
or cocain anesthesia, and is repeated every third or fourth day. 

Massage of the cornea may be used indirectly— i.e., through the eye¬ 
lid; or directly— i.e., by applying pressure with a lens-spoon or spatula 


DISEASES OF THE CORNEA. 


351 


against the opaque spot. Indirect massage with powdered boric acid is 
sometimes followed by improvement. Calomel insufflations should not be 
used in the eyes of persons who are taking the iodids, since the iodid 
excreted in the tears forms with calomel an irritant compound. In case 
massage or insufflation is used, or both together, benefit may follow the 
application of hot packs. 

The administration of 2- or 3-grain capsules of thiosinamin, continued 
for two or three months, has sometimes resulted in the disappearance of 
nebulas. Some cases of dense corneal opacity have shown marked improve¬ 
ment under its use (Suker). 

^ hen such measures have been faithfully tried and seem to have lost 
their value, nothing remains but surgical treatment. The measures of 
this class are numerous, but attention will be directed chiefly to three: 
iridectomy, surface-needling of the cornea, and keratoplasty. In case of 
adherent leucoma a certain amount of clearing of the opacity follows the 
division of adhesions of the iris to the cornea by means of von Graefe’s 
knife or by an iridectomy. However, vision may be made worse by iridec¬ 
tomy because of admission of diffuse light. Tattooage of the cornea may 
be resorted to under such circumstances. In case of great reduction of 
vision from a corneal scar, an optical iridectomy may give a brilliant result. 

Seeley and de Beck have observed marked improvement in vision in 
eyes which had been tattooed and in which the pigment had disappeared. 
This observation lead them to adopt the usual steps of tattooing, omitting 
the India ink. This surface-needling of the cornea is simply pricking the 
opaque tissue with the needle. The conjunctiva is washed with sterile 
water and the pricking is done with a sterile instrument. The operation 
may be repeated at intervals of about a year. In many cases vision will be 

increased from the counting of fingers at seven feet to Y. = 20 / o00 or even 

20 / 

/ 50 * 

Opacities due to a deposit of lead in the cornea are to be treated by 
abrasion. Keratoplasty may be of value in cases of total leucoma in which 
perception of light is present. 

INJURIES OF THE CORNEA (TRAUMATIC KERATITIS). 

Its exposed position renders the cornea liable to injuries of many 
kinds. These include lacerated, incised, and punctured wounds; pressure- 
injury during instrumental delivery; burns and scalds; frostbite from 
excessive application of cold, etc. 

Injuries from Heat and Chemicals.—In this class may be placed those 
cases in which the cornea is injured by heat and chemicals. Hot water, 
burning gases, hot oil, lard; the ends of matches, cigars, or cigarettes; 
and curling-irons are agents often causing injury to the cornea. Naturally 
the interpalpebral part of the cornea is most violently affected by these 
agents. 


352 


MODERN OPHTHALMOLOGY. 


Symptoms. —After injury the eye will be painful; there will be 
profuse lacrimation, photophobia, pericorneal and conjunctival injection, 
with more or less swelling of the conjunctiva and eyelids. There is a muco¬ 
purulent or purulent discharge. The corneal lesion may be limited to the 
epithelial layer, producing a thin, whitish film, which is soon regenerated; 
or the deeper layers may be involved, producing a dense, opaque scar or 
causing perforation. In such severe injuries of the cornea it is the rule 
that the conjunctiva likewise is seriously involved (Fig. 1, Plate X), leading 
to adhesions between the globe and eyelids. 

Treatment. —If the injury is caused by an acid, and the case is seen 
early, an attempt fit neutralization can be made with a solution of bicar¬ 
bonate of potash (saleratus). If lime, caustic potash, or other alkali has 
produced the injury, it may be neutralized with dilute vinegar or lemon- 
juice. The foreign substance should be removed and the conjunctiva 
should be washed thoroughly with sterile water or with physiologic salt solu¬ 
tion. Pain is kept under control by the application of cold compresses, 
which are to be frequently changed, and by the instillation of a 1-per-cent, 
strength solution of holocain. Denuded areas of conjunctiva may be kept 
from growing together by frequently drawing the lid away from the globe; 
however, if the fornix is involved, a symblepharon will surely form. In 
case both ocular and palpebral conjunctiva are burned, and the involved 
ocular area is small, sutures may be used to close the gap in the ocular con¬ 
junctiva and adhesions can thus be prevented. Where two raw surfaces are 
in contact the daily use of the probe and the application of an unirritating 
ointment may prevent or limit adhesions. 

Mechanical Injuries of the Cornea.—These injuries may be inflicted 
in any one of many ways, and may be complicated by the lodgment of 
foreign bodies. Conrpression injuries are sometimes met with in the new¬ 
born as the result of instrumental delivery. In such cases there will be 
bruising of the eyelids and conjunctiva, with dulling of the anterior corneal 
layers, followed by an obliquely placed scar. In the course of several months 
such opacities may entirely disappear. Scratches may be caused by the 
finger-nail, a twig, etc., and are extremely painful and liable to infection. 
Such injuries may he followed by recurrent bullous keratitis. Xot rarely 
the attacks recur several times a year, for two or three years. In this disease 
the attacks invariably come on in the morning, the patient awakening with 
pain, pericorneal injection, and lacrimation. Punctured and incised wounds 
of the cornea usually involve other structures (the sclera or iris and lens). 
Such wounds, without the lodgment of a foreign body, may come from the 
unskillful use of a needle or from the impact of a thorn. Contusions of the 
cornea are not uncommon, and generally other parts of the eye are injured 
at the same time. Injuries by flying pieces of coal are often followed by 
corneal necrosis. 

Symptoms. —Injuries to the cornea are generally followed by severe 
pain, photophobia, lacrimation, pericorneal injection, and reduction in 


DISEASES OF THE CORNEA. 


353 


vision. There is a scratching sensation, leading the patient to believe that 
a foreign body is present. The injured eye should be examined by oblique 
illumination. Denuded areas can be outlined accurately by the use of 
fiuorescin solution. 

Prognosis. —Corneal injuries are peculiarly liable to be followed by 
infection. This is particularly the case in the presence of dacryocystitis. 
Deep wounds always leave a scar, which, if located over the pupil, interferes 
with vision. Penetrating wounds, followed by loss of the aqueous humor 
and sometimes by prolapse of the iris, are chiefly of interest in connection 
with the damage done to the iris, lens, and deeper structures of the eye. 

Treatment.- —Patients with corneal injuries are clamorous for relief, 
and holocain should he used to relieve pain. The conjunctiva should then 
be flushed with a weak bichlorid solution (1 to 5000), atropin should be 
instilled, and the eye should be covered with a light gauze dressing. If the 
injury has been infected, the treatment will be the same as outlined above, 
with the addition of the destruction of the infected area by the curette or 
gal-vanocautery. 

Penetrating wounds of the cornea require careful treatment lest in¬ 
fection occur and spread to the deep ocular structures. The cornea and 
conjunctiva should be washed with a sterile bichlorid (1 to 5000) or salt 
solution (0.5-per-cent, strength). If a prolapsed iris is present, it should 
be cut off. To prevent secondary infection, the wound should be covered 
with a conjunctival flap. If the wound is situated at the periphery of the 
cornea, the simplest method of covering it will be to loosen the conjunctiva 
all around the cornea, and insert a purse-string suture. This is to be tied 
and is left in situ for several days. If the wound involves the centre of the 
cornea, a loosening of the conjunctiva with the excision of a suitable area 
of this membrane, will be required. In simple, clean-cut corneal wounds 
this method of treatment may not be necessary. In lacerated wounds it 
should be adopted. 

Healing of Corneal Wounds.—Since pathologists have made it the 
battle-ground on which to test their theories, much has been written con¬ 
cerning the healing of wounds of the cornea. Systematic writers dis¬ 
tinguish three stages in the reparative process:— 

1. The stage of simple adhesion. 

2. The stage of temporary closure of the wound through epithelial 
plugging. 

3. The stage of definite scar-formation. 

It is impossible here to discuss the minute changes which occur in the 
healing process. For such information the reader is referred to systematic 
treatises on surgical pathology. 

Hemorrhage into the Cornea.—A very rare accident is hemorrhage 
into the layers of the cornea. As a result of trauma, blood is effused be¬ 
tween the layer of Descemet and the substantia propria, and slowly spreads 
until it obscures nearly the whole iris. After a period of two or three 


354 


MODERN OPHTHALMOLOGY. 


weeks the blood is absorbed, leaving some pigment stippling the cornea. 
In a case Qf hemorrhage into the cornea the diagnosis must be made by 
oblique illumination, and it will be necessary to exclude hemorrhage into 
the anterior chamber. Fig. 244 shows a hemorrhage into the cornea as it 
appeared one day after the eye had been struck by a flying cinder, and in 
Fig. 245 the same eye is shown as it appeared one day later. 

Foreign Bodies in the Cornea.—The lodgment of a foreign body in the 
cornea is a common accident. Pieces of iron, steel, brass, copper, coal, stone, 
or wood are among the common missiles. A foreign body may injure only 
the epithelium or it may penetrate deeply into the cornea. The seriousness 
of such an accident depends somewhat on the depth to which it penetrates, 
but chiefly on the condition of the foreign body. If aseptic, little harm 
results, aside from the formation of a scar when penetration has been deep; 
if septic, it may set up a rapidly destructive necrotic process which often 
ends in iritis, perforation of the cornea with its attendant evils, or pan¬ 
ophthalmitis. The size of these missiles varies greatly. Most of them are 


Fig. 244.—Hemorrhage into the cor¬ 
nea. (After de Beck.) 

minute pieces which may defy recognition until after the use of oblique 
illumination, with or without the aid of fluorescin solution. Pain, photo¬ 
phobia, lacrimation, and pericorneal injection follow the injury. 

Treatment. —The indications for treatment are: (1) removal of the 
foreign body, (2) the prevention of infection, and (3) the treatment of 
complications. To remove a foreign body lodged in the cornea is usually 
such a simple affair that some practitioners, it is to be feared, do not observe 
the rules of asepsis. The instruments required are a speculum, fixation 
forceps, corneal spud, and a cataract-needle. Rarely will it be necessary 
to use other instruments, although it is conceivable that a small foreign 
body, lodged deeply in the cornea and projecting into the anterior chamber, 
may best be removed by passing a keratome into the chamber and pressing 
it against the foreign body, while a cataract-needle is applied externally to 
pry the substance out of its bed. In an ordinary case the surgeon proceeds 
as follows: The eye having been anesthetized with holocain, the speculum 
is placed in position and the eye is held quiet with the fixation forceps in 
the left hand, while the right guides the spud or cataract-needle. The in- 



Fig. 245 —The same eve one day 
later. (After de Beck.) 







DISEASES OF THE CORNEA. 


355 


strument is placed under the foreign body and lifts it out. If imbedded 
deeply, the cataract-needle can be used to dig it out. The conjunctiva, 
which previous to the operation should have been flushed with a 1 to 5000 
bichlorid solution, is again washed. Usually it is not advisable to bandage 
the eye. In case the injury is of severe character, atropin and a gauze 
dressing should be used. The patient should be seen once a day until he is 
well. If infection has occurred, the case will require atropin, intermittent 
applications of moist heat, and possibly the galvanocautery. In all opera¬ 
tive procedures about the eye only sterile instruments should be used. The 
practice of removing cinders, etc., with toothpicks, knife-blades, and other 
unclean instruments is a prolific source of corneal ulceration. 

If the foreign body rests against the posterior surface of the cornea, 
and its shape or position is such as to render its removal impossible by the 
procedures which have been described, the surgeon may resort to the tem¬ 
porary renversement of a corneal flap (Gayet’s operation). 

OPERATIONS ON THE CORNEA. 

Abrasion of the Cornea is the scraping or cutting off of the super¬ 
ficial layers. It can be done with a cataract-needle, with the knife of von 
Graefe or that of Beer, or with a small scalpel or curette. The operation is 
performed in a limited area, as a necessary step in the removal of foreign 
bodies, and as a more extensive procedure in the removal of deposits of lead 
in the cornea, or in the removal of opaque masses in ribbon-shaped kera¬ 
titis. Deschamps has advocated curettement of the cornea after the removal 
of the apex of a pterygium. Abrasion (curettement) is frequently done for 
the cure of infected corneal ulcers. 

Paracentesis of the Cornea.—This operation can be performed with a 
cataract knife or needle or with a small keratome. The other instruments 
required are a speculum and fixation forceps. The puncture can be made 
in any portion of the periphery of the cornea. A few drops of aqueous 
humor are permitted to escape, this being facilitated by a turning of the 
instrument on its axis. The operation is indicated by an increase of intra¬ 
ocular tension: glaucoma, hydrophthalmos, iritis. Paracentesis in glau¬ 
coma is especially valuable in the glaucoma following cataract extraction. 
After the evacuation of aqueous a miotic is to be used. Some of these cases 
will recover without further treatment; often, however, an iridectomy is 
more efficient. If paracentesis is indicated in corneal ulcer, the opening 
should be made not through the floor of the ulcer, as is usually advised, be¬ 
cause of the danger of infecting the eye, but, with care, a paracentesis can 
usually be made through normal tissue, and infection should not follow. 

Cauterization of the Cornea, which is useful in the treatment of in¬ 
fected cases and in conic cornea, can be done by chemic, thermic, or electric 
means. The galvanocautery is preferred. After using atropin if the ulcer 
is central, or eserin if it is peripheral, a local or general anesthetic is em- 


356 


MODERN OPHTHALMOLOGY. 


t 


ployed. The galvanocautery is brought to red heat and is applied to the 
ulcer. After all the sloughing material has been destroyed, atropin is used 
and the eye is bandaged. 

In the treatment of conic cornea the reaction and scar are proportionate 
to the extent and intensity of the cauterization. Moderate cauterization is 
followed by prompt healing and limited scars, while extensive cauterization 
causes iritis, suppuration, and sloughing of the cornea. Perforation of the 
cornea should be avoided, but is not necessarily followed by bad symptoms. 
Knapp uses a convex, disc-like electrode at a dull-red heat, and super¬ 
ficially burns an area from the centre of the cornea down and outward about 
four millimetres in diameter. After a few moments a smaller zone within 
the former is treated the same way, and, last, the cold electrode is placed 
in the centre of the area and withdrawn immediately after the platinum 
becomes red. Holocain is the anesthetic used. In the treatment of conic 
cornea by cauterization at least one-half of the pupillary area should be 
spared. 

Excision of the Cornea (Staphylectomy).—This operation may con¬ 
cern the partial or total removal of the cornea. Partial removal can be 



Fig. 246.—Operation for corneal staphyloma. (Knapp.) 


effected by means of a cataract-knife or by a trepan, and has been performed 
for keratoconus, staphyloma, corneal fistula, and large central opacities. 
Total excision is done for complete staphyloma and for various conditions 
as a step of Mules’s operation. 

As regards partial excision, Berry’s method of treatment of partial 
staphyloma is simple and effective. A cataract-needle is passed through the 
base of the protrusion and a cataract-knife is used to cut away the desired 
amount of cicatricial tissue. 

Total excision of the cornea may be done for total staphyloma where 
there is a complete loss of vision. Beer treated these cases by making an 
incision below with the triangular knife which bears his name, and com¬ 
pleted the excision with scissors. The wound gradually closes with a white 
cicatrix. Critchett’s operation is made by first passing four or five long 
curved needles, armed with silk thread, through the anterior part of the 
globe. The staphyloma is then abscissed, the needles are drawn through, and 
the threads are tied. Suppuration in the operated eye, or sympathetic oph¬ 
thalmitis, may occur after this procedure. Knapp, to avoid the danger 
of passing needles and threads through the ciliary body, devised the 



DISEASES OF THE CORNEA. 


355 


following operation: A curved needle is passed through the conjunctiva 
and outer scleral layer at a point four millimetres behind the cornea, 
above and below (Fig. 24G), both nasally and temporally. The threads 
are left in position, the staphyloma is abscissed according to Beer’s method, 
the lens is removed, and the threads are tied. By this operation the 
wound is closed by four vertical threads, each loop forming a suture. When 
they are tied, the wound closes like the mouth of a purse. De Wecker, after 
excising the staphyloma, covers the defect with conjunctiva drawn by a 
purse-string suture. Other methods of corneal excision have been devised 
by Carter, Panas, and Czermak. 

The accidents following these operations are immediate and remote. 
Among the former are hemorrhage and suppuration. Intra-ocular hemor¬ 
rhage, when occurring during the operation, results in expulsion of the vit¬ 
reous humor, while the retina and chorioid appear in the wound. This acci¬ 
dent renders it necessary to change the operation into an evisceration, with or 
without the insertion of an artificial vitreous body, as in the judgment of 
the operator seems best. Suppuration, which was frequent before the era 
of asepsis, and which occurred in case sutures were not used to close the 
wound, is now a rare accident. The remote accidents are glaucoma, plastic 
chorioiditis, the formation of exuberant granulations, and sympathetic oph¬ 
thalmitis. Glaucoma does not occur unless the lens is left in situ or a large 
part of the staphyloma remains. If tardy suppuration or plastic chorioi¬ 
ditis occurs, the stump must be curetted. Polypoid growths in the stump 
call for the use of the cautery. Sympathetic ophthalmitis, so terrible a 
complication, is fortunately of rare occurrence. If threatened, the stump 
should be enucleated and the optic nerve resected to the optic foramen. 
The results of excision of the cornea are very beautiful. The stump serves 
to support an artificial eye, and the cosmetic effect is all that could be 
expected. 

Keratotomy.—This operation, the incising of the cornea, is a step in 
the cataract operation, in iridectomy, in the removal of foreign bodies from 
the anterior chamber, etc. It is not to these that reference is here made, but 
to the keratotomy of Saemiscli, which is applied to the treatment of ulcus 
serpens. This kind of ulcer often fails to improve under treatment less 
heroic than section of the cornea. 

Saemisch’s Incision.- —This operation is indicated in rapidly spread¬ 
ing (serpiginous) ulcers of the cornea, which have involved a considerable 
area and have resisted ordinary therapeutic measures. The necessary in¬ 
struments are a speculum, fixation forceps, and a narrow von Graefe knife. 
A spatula, iris forceps, and scissors should be provided as reserve instru¬ 
ments. 

A local, or preferably a general, anesthetic should be used. The spec¬ 
ulum having been introduced and the fixation forceps applied, the surgeon 
punctures the cornea in its horizontal diameter, at a point one millimetre 
from outside the ulcer. The counter-puncture is made at a corresponding 


358 


MODERN OPHTHALMOLOGY. 


point. The section is then completed by gentle sawing movements, care 
being taken not to turn the knife on its axis lest the iris become prolapsed. 
The completion of the section is followed by a flow of aqueous humor, 
which carries much of the hypopyon with it. The fibrinous mass which 
engages the wound is now to be removed by means of the forceps. A gauze 
dressing and bandage are to be applied, and should be changed several times 
a day. Some authorities advise that the wound be reopened by the spatula, 
this procedure being repeated daily for five or six days. Such treatment 
is likely to be followed by intra-ocular infection. Hence it is unwise. A 
collyrium (made with boric acid, sublimate solution, or argyrol) should be 
used daily. 

Among the complications are: prolapse of the iris, which, since it 
cannot be excised, results in anterior synechia and later may cause sec¬ 
ondary glaucoma; loss of the lens and vitreous body, which will be more 
likelv to occur under local than under general anesthesia, often leads to 
panophthalmitis. Since Saemisch's incision is employed only in desperate 
cases, the complications are of little importance. 

Operation for Fistula of the Cornea.—To obviate the danger of injury 
to the lens during the treatment of a corneal fistula the author proposes 
the following operation: A keratome is to be introduced into the anterior 
chamber as in the first step in the operation of iridectomy. The tip of 
the instrument is to pass beyond the fistulous area, and the instrument is 
then to be held in situ while a cautery is used to destroy the epithelial 
lining, the tag of iris-tissue which is often present in the fistula, and the 
bulging bleb of Descemet’s membrane. The keratome is to be withdrawn 
carefully to avoid injury to the lens. Atropin and a compress bandage are 
to be used in the after-treatment. During the operation the lids should be 
separated by a speculum, and the eyeball’ should be fixed with forceps. It 
is necessary that the forceps should be placed several millimetres behind the 
point at which the keratome is to be introduced. If the forceps be placed 
on the globe at a point opposite the place at which the keratome is to be 
passed, the eye may be subjected to sufficient pressure to cause a rupture 
of the weakened area. The operation must then be postponed until such 
time as the anterior chamber shall have re-formed. 

Temporary Renversement of a Comeal Flap (Gayet's Operation) is 
performed for the removal of foreign bodies which rest against the posterior 
surface of the cornea and cannot be extracted by ordinary means. Under 
general anesthesia and scrupulous cleanliness, the following operation is 
done: 1. With a von Graefe knife the surgeon makes a corneal flap, which 
is somewhat similar to that of a cataract operation. The size and position 
of the flap must be regulated by the site and dimensions of the foreign body. 
2. The flap is seized with forceps and is reversed,— i.e ., is bent upon itself, 
—thus permitting the removal of the foreign body. 3. The flap is replaced. 
A suture can be used if deemed necessary. Atropin and a compress bandage 
are used in the after-treatment. 


DISEASES OF THE CORNEA. 


359 


Tattooing of the Cornea.—This ancient operation was revived in 18G9 
by de Wecker and is employed chiefly in those dense opacities which form 
a marked impediment to vision and constitute a noticeable blemish. The 
operation should not be done upon thin and staphylomatous corneae, since 
it may he followed by iritis, iridocyclitis, or glaucoma. According to Noyes, 
the best results follow where the cornea is of normal thickness or is abnor¬ 
mally thick. In any event, tattooing is not to be resorted to until the 
pathologic process is quiescent. Colored tattooage was employed by the 
ancients, but at present only black is used. The operation requires a quiet 
(non-irritable) eye, a patent drainage apparatus, and an aseptic conjunc¬ 
tiva. Most text-books advise that the white spot be made black, the Taylor 
needle being the instrument used. While this method undoubtedly im¬ 
proves its appearance, the eye looks unnatural, because its most character¬ 
istic feature—a black central pupil—is wanting. To obtain this, Barck 
advises the surgeon to tattoo a round central spot, leaving a surrounding 
area unstained, so that the pupil will show by contrast, while the periphery 
is tattooed and made to resemble as far as possible the iris of the normal eye. 
The making of a round pupil is much simplified hy employing Barck’s 
instrument (Fig. 247) consisting of two parallel cutting rings, the inner 



Fig. 247. —Tattooing instrument. (Barck.) 


marking the limits of the pupillary space, while the outer marks the inner 
border of the iris-ring. These boundaries having been defined, the tattooing 
is finished by means of an instrument consisting of a bundle of needles. 
Under local anesthesia, the eyeball being held with blunt forceps to avoid 
tearing of the conjunctiva and staining of this membrane, a number of 
obliquely directed stabs are made through the epithelial layer, and the ink 
is rubbed into the openings. The eye is irrigated with sterile water and 
the effect noted. The process is repeated at intervals of two or three 
weeks until the proper coloration has been secured. Atropin is instilled 
and a bandage is applied for a few days. The substance used is the best 
quality of Chinese or India ink, made into a sterile solution as thick as oil 
or paste. The result may remain for many years, but in some cases the 
pigment is absorbed in a few months. 

Among the rare accidents following this operation Terson mentions 
infection of the cornea (causing panophthalmitis), perforation with the 
tattooing needle, iridocyclitis, and sympathetic ophthalmitis. Recently 
Trousseau has observed a case where tattooing of an eye with adherent 
leucoma produced iridocyclitis and sympathetic ophthalmitis, with resulting 
blindness. The same author has once observed sympathetic ophthalmitis 
following: tattooing of the cornea for non-adherent leucoma. 

O O 








360 


MODERN OPHTHALMOLOGY. 


During the operation care should be taken not to tear the conjunctiva 
with the fixation forceps, since this will result in tattooage of the conjunc¬ 
tiva. To avoid this accident it has been proposed to use fixation forceps 
made of bone, ivory, or rubber. 

After the operation, the particles of charcoal are held in the super¬ 
ficial corneal lamellae beneath the epithelium. The black coloration is not 
permanent. If the patient is seen several years after the tattooage the 
grains of charcoal will be found to have moved, occupying an excentric 
position or even invading the transparent tissue. 

Keratoplasty.—In cases of total leucoma with good perception of light, 
the transplantation of a piece of the cornea of a lower animal into a 
bed in the eye of a human being has been practiced. The operation dates 
from the time of Iteisinger (1828), and has claimed the attention of many 
able surgeons. Yon Hippel, who has devised a trephine for the rapid and 
accurate execution of the operation, has met with some encouraging results, 
some of his patients having been able to see through the transplanted tissue 
for many months. He uses a button from a rabbit’s cornea for transplanta¬ 
tion. The insertion of an artificial cornea, or rather the insertion of a 
piece of glass into the cornea, was practiced by Nussbaum (1856). While 
immediately successful, the end was a failure. 

In recent years Fuchs, who possesses an abundance of clinical material, 
has often successfully transplanted a piece of the human cornea, using for 
this purpose the immediately enucleated eye of another patient. This, of 
course, can be done only under favorable surroundings, in large clinics, and 
under strict adherence to rules of asepsis. The eye from which the disc 
is to be taken, and that into which it is to be inserted, must be made 
surgically clean. Two surgeons then work simultaneously. While the one 
is removing a disc from the leucomatous eye the other is enucleating the 
eye of the patient who furnishes the graftive material. It is necessary to 
avoid opening Descemet’s membrane. If this occurs, aqueous humor will 
come in contact with the graft and the result will be a failure. 


CHAPTER IX. 


DISEASES OF THE SCLERA. 

CONGENITAL ANOMALIES. 

These include melanosis, tumors, and certain staphylomas. Con¬ 
genital pigmentation of the sclera (melanosis scleras) presents either small 
spots or diffuse areas of discoloration. Generally there are similar condi¬ 
tions in the iris and chorioid. It is around the openings for the passage 
of the anterior ciliary veins and about the optic-nerve entrance that branch- 
ing pigment-cells are found. Acquired pigmentation occurs in some cases 
of Addison’s disease. 


TUMORS OF THE SCLERA. 

Tumors of the sclera are of rare occurrence. Serous cysts have been 
recorded by Rogman and Hasner. The origin of such tumors is in doubt. 
Some authorities hold that they are dilations of the canal of Schlemm. 
Others state that they are due to a congenital fistula from the anterior cham¬ 
ber into the sclerotic, which permits the aqueous humor to pass between the 
lamellae of the sclera. Some authors attribute them to encysted chorioidal 
exudates producing small staphylomata of the sclera. The diagnosis may 
present difficulties. In Kogman’s case the tumor collapsed on puncture 
without change in the anterior chamber. Among the solid tumors a fibroma 
was described by Saemisch and an osteoma by Watson. Malherbe reported 
a tuberculous tumor of the sclera. Quaglino described a case of telangiec¬ 
tasis of the sclera. Of 137 malignant tumors of the exterior of the eyeball, 
Noyes found that 20 arose from the sclera and 31 from the corneoscleral 
junction. The proper treatment of scleral tumors is excision. 


INFLAMMATIONS OF THE SCLERA. 

Affections of the sclera belong to the class of uncommon ophthalmic 
diseases. The sclera is slow to take on inflammation, and, when once 
scleritis is inaugurated, recovery is slow, as might be expected from such 
a structure. Scleritis may be superficial or deep, acute or chronic, diffuse 
or circumscribed. Of the inflammations affecting this part, the most com¬ 
mon is that known as episcleritis, in which the pathologic process involves 
the loose tissue over the sclera and possibly the superficial scleral layers also. 

Episcleritis (Superficial Scleritis) is a localized inflammation which 
produces an exudate into the episcleral tissue. I he exudation causes a 
protuberance, which is usually rounded or flat and is situated at a distance 

(361) 


362 


MODERN OPHTHALMOLOGY. 


of several millimetres from the cornea. The mass is attached to the sclera, 
and the conjunctiva can be moved over it. Two kinds of injection are 
visible in a case of episcleritis: a superficial hyperemia of the conjunctiva 
and a deeply placed violet-colored injection from the episcleral vessels 
(Fig. 6, Plate X). The eye is red only in the neighborhood of the nodule, 
which is hard and, if it enmeshes one of the ciliary nerves, is acutely sensi¬ 
tive to the touch. The subjective symptoms in episcleritis may be mild or 
severe, but the course of the disease is subacute or chronic. In some cases 
photophobia, lacrimation, and a dull, heavy pain are symptoms. After sev¬ 
eral weeks the affection usually disappears, the nodule is absorbed, and either 
no trace is left or a slate-colored patch remains to mark the site. In some 
cases other nodules form until the entire circumcorneal zone is involved. A 
characteristic feature of the disease is the tendency to recurrence, either in 
the old site or elsewhere. The process may persist for months or even years. 
The inflamed patch frequently resembles phlyctenular conjunctivitis, with 
which it may be confounded. Although, as a rule, the cornea is unaffected 
in episcleritis, if the nodule is located near the cornea, an infiltration of the 
latter may occur during the height of the disease. Iritis is rarely a compli¬ 
cation. Both eyes may be involved in episcleritis. 

Etiology.— The etiology of episcleritis is somewhat obscure, although 
it undoubtedly can be attributed to gout or rheumatism in some cases. 
Exposure to cold, menstrual derangement, and scrofula are supposed causes. 
Syphilis is rarely an etiologic factor. 

Pathology. —In episcleritis the conjunctiva, the episcleral tissue, and 
the superficial scleral layers are involved. The conjunctiva is hyperemic 
and the episcleral tissue is edematous. The superficial scleral layers show 
abundant fibrinous and cellular infiltration, with dilation of lvmph-vessels 
and blood-vessels. The walls of the vessels are generally thinner than nor¬ 
mal and are surrounded by an area of cellular infiltration. Hemorrhages 
may be present or absent. The inflammatory products do not tend to dis¬ 
integration; they disappear by resorption. There is not a clearly defined 
line of demarcation between episcleritis and scleritis, transition forms 
existing. 

Diagnosis. —In fully developed cases there can be little difficulty 
in the diagnosis. Episcleritis may be mistaken for phlyctenular conjunc¬ 
tivitis. In the latter affection there is present a denuded area of a whitish- 
yellow color, and the whole inflamed patch is movable with the conjunctiva. 

Darier states that the diagnosis of episcleritis from conjunctivitis is 
facilitated by the use of adrenalin, which produces marked anemia of all the 
conjunctival tissue, but leaves a hyperemic spot.at the level of the episcleral 
inflammation. 

Prognosis. —Episcleritis generally lasts one or two months, but may 
continue longer. Eecurrences are not infrequent. In general, the prog¬ 
nosis is favorable; exceptionally the deeper layers will be involved, leading 
to ectasise. 


DISEASES OF THE SCLERA. 


363 


Treatment. —In the treatment of episcleritis it is necessary to attend 
to the general health. Gastric and uterine disorders should receive appro¬ 
priate treatment. Salicylate of sodium, aspirin, and colchicum are valuable 
remedies for internal use. Pilocarpin by the mouth or hypodermically will 
often produce an amelioration of the symptoms. Massage, heat applied by 
the Japanese hot box, and the subconjunctival injection of a solution of 
bichlorid of mercury (1 to 3000) are valuable therapeutic measures. Ad¬ 
renalin, applied three or four times daily, is of value. After each applica¬ 
tion gentle and prolonged rotary massage with mercurial lanolin is to be 
practiced (Darier). Injections of salicylate of sodium (2 per cent.), of cin- 
namate of sodium (hetol), or of salt solution have been recommended. As- 



Fig. 218. —Deep scleritis. (Author.) 


i Photomicrograph by Dr. H. P. Wells.) 

1, 2, Superficial infiltration. 3, Area of deep infiltration. 4, Ciliary muscle. 

tringent metals and caustics should not be used. If the cornea is involved, 
atropin should be applied, but with due caution in elderly persons. In 
rebellious cases, and in those which are prone to recur, it will be advisable 
to excise the inflamed patch. Scarification and curettage have been em¬ 
ployed by some surgeons. Attention should be given to the state of the re¬ 
fraction and of the muscle-balance. 

Fugacious Episcleritis (Episcleritis Partialis Fugax; “Hot Eye”) is 

a form of sudden transient hyperemia of the episcleral tissue and overlying 
conjunctiva. It lasts for a few days and reappears at intervals varying 
from a few weeks to several months. There is pain, photophobia, and 
lacrimation, but vision is unaffected. The disease occurs chiefly in adults 
of a rheumatic or gouty diathesis, but children are not exempt. The 



3G4 


MODERN OPHTHALMOLOGY. 


affection is supposed to be identical with that described in 1892 by Dr. 
Burnett, of Washington, as “a vasomotor dilation of the vessels.” 

The name “hot eye” was given to the disease by Hutchinson. The 
treatment is the same as that outlined above for episcleritis. 

Scleritis (Deep Scleritis) is a much less frequent disease than epi¬ 
scleritis. It is a much more obscure disease, and in the early stages can 
be recognized with difficulty, since, in the absence of a microscopic section, 
it is impossible to say how deeply an episcleral inflammation has extended. 
• Early in its history the presence of scleritis is to be inferred from the 
existence of complications, such as iritis, chorioiditis, and sclerosing kera¬ 
titis. Scleritis may be acute or chronic, diffuse or circumscribed, anterior 
or posterior. As an example of the acute type, mention may be made of 
the inflammatory thickening of the sclera which occurs in orbital cellulitis 
and panophthalmitis (Fig. 291). The posterior scleritis which is found in 
myopia involves the chorioid, and is called posterior sclerocliorioiditis (see 
chapter on the chorioid). As a result of inflammation, the sclera becomes 
softened. The normal or increased intra-ocular tension causes the mem¬ 
brane to bulge (ectasia of the sclera). Scleritis tends to extend until the 
entire cornea has been circumscribed (Fig. 249). 

Early in its history scleritis presents a diffuse or circumscribed area 
of bluish-red or violaceous injection, situated in the ciliary region. Pain 
and lacrimation are prominent symptoms. The inflamed tissue resembles 
the patch of episcleritis, but is less sharply defined. When the acute process 
has subsided, the circumcorneal zone will appear of a violet color, resem¬ 
bling porcelain; if the sclera is much thinned, the affected area will be of 
a bluish tint, which is given to it by the subjacent chorioid and ciliary 
body. Deep scleritis generally involves both eyes, and presents important 
complications (iritis, cyclitis, keratitis) which seriously impair vision. 

Sclerosing Keratitis .—In this affection, which is an accompanying 
symptom of scleritis, the corneal limbus is invaded by a dense opacity which 
creeps over it. Apparently the sclera has pushed its wav into the cornea. 
The opacity may appear as a semicircle or circle, but frequently it is an 
irregular patch with prolongations. Its base is directed toward the in¬ 
flamed sclera. The disease may be unilateral or bilateral. Iritis or cyclitis 
may be present or absent. The corneal opacity, which at first is grayish 
or yellowish, may be thick and permanent, or it may be partly clear. Early 
in the disease tension may be increased; later on, when cyclitis, hyalitis, 
hemorrhages, and vitreous opacities ensue, the tension will be subnormal. 
Like the scleritis which causes it, sclerosing keratitis may often recur. In 
some cases the entire cornea, with the exception of a small pupillary area, 
becomes opaque. 

Sclerolcerato-iritis is the term applied to a complicated disease affecting 
the structures at the corneoscleral junction. It also is known as scrofulous 
scleritis, anterior uveitis, or anterior chorioiditis. Relapses are common 
and the disease often is intractable. It begins with the clinical signs of 


DISEASES OF THE SCLERA. 


3G5 


an anterior scleritis; soon the cornea is affected and may go on to ulcera¬ 
tion; the iris is involved and posterior synechiae form. Under appropriate 
treatment the condition improves, but relapses often occur. Such cases 
often end in partial or total loss of vision from cyclitis and hyalitis. 

Etiology. —Deep scleritis may be due to syphilis, scrofula, rheuma¬ 
tism, gout, or tuberculosis. It may result from exposure to cold. Gonor¬ 
rhea, when associated with synovitis, is a cause. Disorders of menstruation 
are often present in females with deep scleritis. Sclerosing keratitis is 
sometimes found in adults who apparently are of robust constitution. 



Fig. 249.- —Sclerosing keratitis. (After Demotjrs.) 

(Drawn by Dr. E. W. Mills.) 

Pathology. —In the few unquestioned cases of scleritis which have 
been subjected to microscopic examination, a variety of changes has been 
found. In Baumgarten’s case the sclera was thickened, measuring four 
millimetres, a condition which was due partly to an infiltration of small, 
round cells between the scleral bundles, partly to an increase in the number 
of fibres. In a case of old uveitis and scleritis Kostenitsch found abundant 
round-cell infiltration, numerous polynuclear leucocytes, and small hemor¬ 
rhages in the sclera, and an increase in the number of scleral cells and of 
blood-vessels. Edema and discoloration of the scleial fibres was noted by 
Schirmer. As a result of degenerative changes the sclera loses its resisting 
power. Under such circumstances the intra-ocular pressure may lead to 



366 


MODERN OPHTHALMOLOGY. 


the formation of ectasiae. Atrophy does not always follow scleritis. The 
inflammation may result in proliferation, a formation of new tissue, and 
thickening of the membrane, with a formation of new blood-vessels. Since 
these changes are limited to that part of the sclera covering the ciliary 
body, and reach their greatest intensity at the points where the ciliary vessels 
pierce the sclerotic, it is reasonable to agree with Greeff, that deep scleritis 
is a secondary process, a consequence of a circumscribed uveitis which has 
extended along the sheaths of the vessels in the sclera. Gelatinous infiltra¬ 
tion, purulent inflammation, and ulceration of the sclera have been recorded. 

Treatment. —The treatment of deep scleritis includes the correction 
of any departure from health. In rheumatic cases the administration of 
salicylate of sodium, or aspirin, colchicum, salol, the alkalies, iodid of 
potassium, or of caffein, and the free use of water internally, will be 
appropriate measures. In scrofulous subjects a course of codliver-oil, with 
or without iodin and iron, will be in order. A change of climate will often 
be advisable. If tonics are indicated, iron, arsenic, and quinin should be 
given. In many cases diaphoresis is followed by improvement. The 
syphilitic cases will need mercury, which is a valuable remedy on general 
principles. The local use of atropin is of great importance, not only to 
‘draw the iris out of the way of harm, but to abolish accommodative effort. 
If the tension is increased, arecolin should replace atropin and repeated 
paracentesis of the anterior chamber must be resorted to, one or two drops 
of aqueous humor being evacuated every second or third day. The local 
use of moist or dry heat will be valuable to relieve pain. In some cases 
it will be necessary to give the patient a solution of holocain or of dionin to 
use whenever the pain is severe. AVhen inflammation has subsided and has 
left the sclera weakened, the prolonged use of a mild miotic, combined with 
massage of the eye with a bland mercurial ointment, will serve to promote 
the absorption of the interfibrillarv deposits. For the same purpose, thio- 
sinamin (gr. ii or iij, three times a day), given in capsules, may be of value. 


PROTRUSIONS OF THE SCLERA. 

Ectasiae of the Sclera (Scleral Staphylomata) are classified as anterior, 
posterior, and equatorial. Anterior scleral and equatorial staphylomata 
appear as bluish-black or grayish projections. Their color is due to the 
thinned sclera permitting the dark chorioid to appear. In anterior ectasiae 
the limbus of the cornea forms the anterior border of the projection; in 
some cases both cornea and sclera participate in the bulging. Anatomic 
examination of enucleated eyes shows two forms of anterior scleral ectasia?, 
the ciliary and the intercalary. The former shows a bulging of that part 
of the sclera which is lined by the ciliary body, while the latter is a pro¬ 
trusion between the ciliary body and the corneal margin. 

Equatorial ectasia? can be seen only when the eye is turned strongly 
to the side opposite the projection. Ectasiae occur at one or more places. 


DISEASES OF THE SCLERA. 


367 


where the venre vorticose pass from the globe, but are said not to form a ring 
such as sometimes occurs in anterior staphyloma. The 3 r are the result of 
chronic chorioidoscleritis. On microscopic examination the chorioid and 
sclera are found atrophic and adherent. 

The posterior ectasias involve the posterior segment of the globe. They 
cannot be seen except the eye be removed or the ophthalmoscope be used. 
These posterior projections are divided into (1) the posterior staphyloma of 
Scarpa and (2) the posterior staphyloma of von Ammon. The former is 
a protrusion situated at the temporal side of the optic-nerve entrance. If 
large, it involves the nerve itself. Arlt discovered that this form of ectasia 
is frequently the cause of myopia (axial myopia). The antero-pos(erior 
diameter of the globe is elongated, and the fundus shows a white crescentic 
patch embracing the temporal side of the disc. The posterior scleral pro- 



Fig. 250.—Equatorial ectasias of the 
sclera. (After vox Ammox.) 

trusion of von Ammon lies below the posterior pole, and is a congenital 
condition which arises from incomplete closure of the fetal eye-cleft. At 
the present day it is best known by the name inferior conus. Often in such 
cases there is an accompanying coloboma of the chorioid and iris. The 
conditions described above are partial ectasias. It is now necessary to 
speak of 

Total Ectasia of the Sclera .—While in the adult the sclera is rigid, 
and gives way only in certain weak places, in the young subject the eyeball 
can be enlarged in every direction. Such an ectasia of the sclera is often 
accompanied by an enlargement of the whole cornea (megalocornea) or by a 
corneal staphyloma. In this connection the reader should refer to con¬ 
genital anomalies of the cornea. 

The causes of scleral ectasia include those factors which either diminish 
the resistance of this coat or increase intra-ocular pressure. Thus, glaucoma 



Fig. 251.—Cirsoid ciliary staphyloma. 
(Vossius.) 




368 


MODERN OPHTHALMOLOGY. 


and exclusion of the pupil by iritis belong to the latter class, while dimin¬ 
ished resistance of the sclera follows scleritis, tumors, gummata, tuber¬ 
cular nodules, injuries, and the congenital condition mentioned above. 

The results of scleral ectasia are loss of vision from increase of tension, 
great disfigurement in the anterior and equatorial forms, and constant irri¬ 
tation from exposure of the protruding mass after it reaches such dimen¬ 
sions that the lids cannot cover it. The posterior protrusion in staphyloma 
often leads to great increase in the near-sight without producing increased 
tension. Vision is often much reduced in these cases. The ectasia of von 
Ammon remains stationary, and, since it is situated below the macular 
region, it does not impair vision. 

Treatment. —Anterior and equatorial ectasias of the sclera should be 
treated by iridectomy, for the purpose of reducing tension. If this is accom¬ 
plished, the process stops. If iridectomy cannot be performed, the eye is 
to be left to its fate, and ultimately an enucleation will often become neces- 



Fig. 252.—Posterior staphyloma of Fig. 253.—Ciliary staphyloma. (Pagen- 

Scarpa. stecher and Genth.) 

sarv. The treatment of the posterior staphyloma of Scarpa is discussed 
under the head of “Chorioiditis.” 


INJURIES OF THE SCLERA. 

The sclera may be bruised, burned, or cut. Bruises result from con¬ 
tusions, compression, or concussion, and necessarily concern the other tunics. 
The sclera may be ruptured as the result of the direct or indirect applica¬ 
tion of violent force (Fig. 6, Plate XII). The line of rupture is gen¬ 
erally placed concentrically with the cornea, at a distance of two or three 
millimetres from the limbus, and is frequently situated above the horizontal 
meridian (Praun). The length of the rupture varies from three to twelve 
millimetres. Wounds of the sclera may be divided into (1) those without 
and (2) those with the lodgment of a foreign body within the eye. 

Wounds of the sclera without the lodgment of a foreign bodv may be 
incised, contused, or punctured. They may be clean cuts or lacerations, 
and are caused by a variety of agents, varying from a blow by the fist to 
cuts by knives, pieces of broken glass, birdshot, or chips of metal. They are 
always serious by reason of the injury done to other parts,—such as the 


DISEASES OF THE SCLERA. 


369 


ciliary body, cliorioid, and retina,—and because of the danger of infection. 
Often the vitreous protrudes from the wound, or the lens and a large part 
of the vitreous humor will be lost. The sclera may be ruptured by blunt 
instruments while the conjunctiva is intact over it, but such injuries are 
rare. Usually a scleral wound is easily recognized, and presents a portion 
of the iris, ciliary body, cliorioid, or vitreous as a hernial protrusion. The 
vitreous will be filled with blood if the wound is situated posteriorly; if far 
forward, there will be hemorrhage into the anterior chamber. Small scleral 
wounds may be covered by a subconjunctival hemorrhage, in which case 
reduced tension will be a valuable diagnostic sign. Clean cuts of the sclera 
and some lacerated wounds, with incarcerations of part of the uveal tunic, 
often heal with surprisingly little reaction, and the same result may occur 
after loss of considerable vitreous and the lens. In favorable cases healing 
occurs in four or five weeks. 

Rupture of Schlemm's Canal often occurs after a contusion of the 
limbus by a blunt bod} T , and follows incomplete rupture of the ocular cap¬ 
sule. Under such circumstances, blood escapes from the canal and forms 
a coagulum at the periphery of the anterior chamber. The injury is fol¬ 
lowed by the appearance of diffuse corneal opacity and of opaque lines which 
radiate from the limbus. The patient complains of a feeling of pressure 
and of a red cloud before the eye. If the injury is limited to the rupture 
of the walls of Schlemnvs canal, the prognosis will be favorable. 

Treatment .—Large tears in the sclera, with loss of most of the vitreous 
humor, and extensive damage to the cliorioid and retina, will call for imme¬ 
diate enucleation or the performance of Mules’s operation. In case the eye is 
less severely injured and some vision remains, the surgeon should attempt 
to save the organ. To this end a general or local anesthetic is used; the 
eye is carefully washed in a weak bichlorid or normal salt solution; pro¬ 
truding pieces of vitreous, iris, or cliorioid are excised; and the lips of the 
scleral wound are united with sterile catgut sutures. In scleral ruptures 
concentric with the cornea Nuel’s method (Fig. 254) of stitching will be 
useful. A thread armed with two needles is passed beneath the conjunctiva 
near the equator and is made to encircle the cornea. When tied, it causes 
the lips of the scleral wound to approximate. Atropin is then instilled, a 
bandage is applied, and the patient is confined to bed. If infection occurs, 
the case will probably require enucleation; if infection does not occur, 
useful vision may be saved. Intra-ocular tension may rise after the closure 
of a scleral wound, thus causing secondary glaucoma or staphyloma. The 
eye may shrink, become tender on pressure, and be a cause of sympathetic 
ophthalmitis. It is justifiable to attempt for two weeks to save a severely 
injured eye, since sympathetic inflammation will not occur within that 
period, and at the end of ten days the intelligent surgeon will be able to 
foretell the fate of the eye. Exploration of a scleral wound with a probe 
passed into the vitreous body is dangerous, because of the liability of intro¬ 
ducing pathogenic germs. 


24 


370 


MODERN OPHTHALMOLOGY. 


In some cases of beginning infection the eyeball can be saved by a 
series of procedures which includes the destruction by fire of the focus of 
infection. Suppose, for example, a corneoscleral wound has been received, 
the lens and iris have been injured, the instrument causing the wound has 
been removed ( i.e there is not a foreign body in the eye), but there is 
beginning infection of the wound and of the anterior portion of the vitreous 
body. In such a case the patient should be anesthetized, a large corneal 
incision should be made, and this should be followed by a large iridectomy, 
and by delivery of the lens. Then the foci of infection should be destroyed 
with the electric cautery, iodoform should be placed within the globe, and 
a compress bandage should be applied. In many instances this heroic treat¬ 
ment will save the eyeball, although vision will generally be lost. 

Foreign Bodies in the Sclera are not often seen, since such sub¬ 
stances are generally propelled with force sufficient to cause them to enter 
the vitreous chamber. However, pieces of iron, steel, glass, stone, per¬ 
cussion-caps, grains of gunpowder, etc., sometimes lodge in the sclera. If 
not visible, their location can often be determined by x-ray localization. 



Fig. 254.—Stitch for scleral rupture. (After Nuee.) 

In case the suspected foreign body is iron or steel, the sideroscope may be 
useful in diagnosis, or the Haab magnet can be used. The latter localizes 
the foreign body by the pain which follow's its application. 

Foreign Bodies in tile Eyeball. —If an eye has been injured, the 
surgeon should try to determine whether the missile has lodged within the 
globe. The history of the case, the statements of witnesses, and the appear¬ 
ance of the wounding substance (if large) may aid in solving the question. 
A foreign body may pass through the globe and lodge in the orbit, or it 
may rest in any of the ocular structures, the vitreous chamber being a 
favorite location. If the body is loose, its tendency is to sink to the lower 
and anterior part of the vitreous chamber, adjacent to the ciliary body. 
While foreign substances may remain within an eye for long periods with¬ 
out exciting inflammation, such a state of affairs is highly dangerous. 
Owning to its location, to the hemorrhage resulting from the injury, to the 
opacity of the lens, or to the presence of inflammatory products around the 
missile, it rarely happens that the foreign body is visible to ophthalmoscopic 
examination. Consequently its presence can be determined only by an 
x-ray examination; or, if the substance be iron or steel, by the use of a 



DISEASES OF THE SCLERA. 


371 


giant magnet. It is only in the case of minute splinters, one millimetre 
or less in diameter, that the x-ray examination may fail to detect a foreign 
body. Naturally the method employed for the removal of an extraneous 
substance will be determined by its nature. 

Magnetic Foreign Bodies .—If the injury has been inflicted by a piece 
of iron or steel, which is supposed to have lodged in the eye, the patient 
should be subjected to the influence of a Haab giant electromagnet at the 
earliest possible moment. The instrument should be provided with a rheo¬ 
stat. The patient being seated or lying on a table, the eye is anesthetized 
with cocain or holocain and the tip of the magnet is applied to the eye before 
the current is turned on. If the metal has entered the eye behind the lens, 
the tip of the magnet is to be applied to the enlarged wound of entrance. 
If the original wound is too small to be seen, a scleral opening is to be made 
with a von Graefe cataract-knife, the incision being made between two of the 
recti muscles. If the lens is clear, the magnet is to be applied to the ciliary 
region and later to the cornea. By this method it is possible to draw a 
foreign body around the periphery of the lens. The presence of the foreign 
body behind the iris will be indicated by pain and by bulging of the iris. 
The piece of metal is then to be drawn into the anterior chamber, from 
which it can be readily extracted through a corneal opening. If the lens 
is opaque, the magnet is to be applied to the centre of the cornea. 

If the use of the giant magnet fails to detect the metal, an x-ray 
picture should be made. The location and size of the foreign body having 
been determined, if the substance is magnetizable, the surgeon can choose 
between two methods, viz.: (1) he can make a scleral incision over or near 
to the site of the foreign body and then introduce the tip of a Hirschberg, 
Lippincott, Johnson, or Sweet hand-magnet; or (2) he can bring the 
front of the patient’s eye close to a giant magnet, using this instrument 
to draw the foreign body forward through the vitreous body, past the zonula 
of Zinn, and thence through the posterior into the anterior chamber, from 
which it is to be removed through a corneal section. The first of these 
procedures will be done under general anesthesia; the second should be 
accomplished under the influence of cocain or holocain, since the patient’s 
co-operation is necessary to its success. It is not yet time to decide which 
is the better method. Since few cases occur in which a foreign body, 
located in the vitreous chamber, is visible ophthalmoscopically, the giant 
magnet will be the better, in the absence of a sciagraphic examination. 
The sensation of pain, which follows when the tip of the giant magnet 
approaches the location of the foreign body, is of diagnostic value. The 
hand-magnet possesses important advantages over the giant instrument in 
that it is portable and comparatively inexpensive. 

Sweet states that the Kontgen rays offer the most certain method of 
locating intra-ocular foreign bodies, and he favors the use of this method 
of examination before resorting to the use of a magnet. On the other hand, 
Fisher believes that in every case of suspected foreign body (iron or steel) 


372 


MODERN OPHTHALMOLOGY. 


within the eye, the patient should be immediately subjected to the magnet 
test. The giant magnet will often aid the diagnosis in two ways: (1) by 
pain, which is caused by the movement of the foreign body; and (2) by 
the bulging of the iris, which occurs when a foreign body has been drawn 
forward through the vitreous humor and around the lens and impinges on 
the posterior surface of the iris. The early use of the magnet may lessen 
the danger of infection. The earlier the magnet is used, the better will be 
the prognosis. If a speculum and fixation forceps are required during the 
operation, they should be non-magnetic: i.e., made of brass or aluminum. 
In applying the giant magnet the current is to be turned on gradually until 
the full force is obtained. If the foreign body does not appear, the current 
is to be turned off and reapplied with the tip of the magnet in a new posi¬ 
tion. If a foreign body of large size lies horizontally in the vitreous humor, 
it will approach the magnet lengthwise, thus obviating the danger of tear¬ 
ing the internal ocular structures. 



Fig. 255.—Giant magnet. 


Results of Magnet Operations .—While it is impossible to furnish data 
regarding the use of the hand-magnet, since many unsuccessful cases have 
not been reported, the statistics of giant-magnet operations are fairly com¬ 
plete. Haab, of Zurich, and Fisher, of Chicago, have recently published 
their results. 


Haab’s Statistics. 

Total number of eyes.165 

Number of failures. 23 

Number of eyes from which splinters 

were extracted .141 

Number of eyes requiring enuclea¬ 
tion . 39 

Number of sightless eyes preserved. 19 
Number of eyes requiring a cataract 
operation (of these, 51 recovered 
useful vision). 71 


Fisher’s Statistics. 

Total number of cases.150 

Symptoms of metal in eye, but nega¬ 
tive result with magnet. 49 

Metal removed . 97 

Metal found in eyeball after enuclea¬ 
tion—“magnet negative”. 4 

RESULTS. 

Good vision . 90 

Sightless eyes—“external appearance 

good” . 34 

Enucleations . 20 
















DISEASES OF THE SCLERA. 


373 


Causes of Failure with the Giant Magnet are mentioned by Haab in 
these words: “Of the whole number of 1G5 cases in my experience, the 
operation failed only 23 times. The operation was successful in 141 cases, 
or in 86 per cent. If we consider the 134 difficult cases in which the 
splinter penetrated behind the iris and the lens, we find that in these 134 
cases the large magnet failed only 23 times to extract the splinter from 
the eye, and was successful in 111 cases, or 83 per cent. These failures 
were due to the following circumstances:— 

“1. The foreign body was seated too firmly in the back wall of the globe 
or had pierced it completely. 

“2. The splinter was seated in the ciliary body at first or was drawn 
there by mistake. 

“3. The splinter had produced fibrino-purulent exudation, which, 
according to my experience, greatly hinders its movability. 

“4. The splinter had been healed over in the course of months or years.” 

Removal of Non-magnetic Substances .—These foreign bodies can be 
located in almost all cases by means of the x-rays. They should be removed 
with forceps introduced through an incision in the most available part of 
the sclera. 

Operations on the sclera (anterior and posterior sclerotomy) will be 
described in the chapter on glaucoma. 


CHAPTER X. 


DISEASES OF THE IRIS. 

The iris is subject to congenital malformations, tumors, inflammations, 
functional disturbances, and injuries. 

CONGENITAL ANOMALIES. 

They are coloboma, persistent pupillary membrane, corectopia, poly- 
coria, anirida, ectropion of the uvea, heterochromia, albinism, tumor, at¬ 
rophy, and adhesion to the cornea. 

Coloboma of the Iris may exist alone, but generally is found with a 
like condition of the chorioid or ciliary body. In most cases the coloboma 



Fig. 256 —Congenital coloboma of the iris. (Seggel.) 

is below, but it has been seen outward, upward and outward, and upward 
and inward. When the cleft is spanned by a membrane, the condition is 
called “bridge coloboma.” The extent and shape of the defect are subject 
to great variations. Alone, it does not impair vision, but, being often asso¬ 
ciated with coloboma of the chorioid and retina, or with microphthalmos, 
or with coloboma or displacement of the lens, the patient’s vision is likely to 
be much reduced. The cause of the defect is not known. Lang and Col¬ 
lins say that it is not due, as some have supposed, to an unclosed fetal fissure 
of the iris, since this structure is not developed in two sectors, and the nor¬ 
mal fetal iris never has a cleft. The condition is not amenable to treatment. 

Persistent Pupillary Membrane is the most frequent of the anomalies 
of the front of the globe. This membrane, formed from the anterior fibro- 
vascular sheath of the lens, in man should disappear before birth. If a 
portion remains, the condition named is the result. This anomaly is present 
in about 1 per cent, of cases. The persistent membrane varies in color, 
extent, and relationships. The commonest form is a single fine thread, 
passing from the front of the lens to an attachment on the anterior face 
(374) 


DISEASES OF THE IRIS. 


375 


of the iris near its inner circle. There may be several attachments simu¬ 
lating iritic adhesions. The fact that they arise from the front of the iris, 
which can be determined by oblique illumination, serves to distinguish them 
from posterior synechiae. The normal action of the iris is not interfered 


Fig. 257.—Persistent pupillary fibres, forming loops. (De Beck.) 

with by these congenital tags. The condition is much more often unilateral 
than bilateral. 

Corectopia is an abnormal position of the pupil. Often the pupil is 
found slightly excentric, but marked displacement is very rare and is usu- 


Fig. 258.— Forms of persistent pupillary membrane. (De Beck.) 

ally an accompaniment of ectopia lentis. The displaced pupil is often 
small, irregularly circular or slit-shaped, and inactive. It may be associated 
with the presence of granular opacity and blood-vessels on the lens, as in 
the case reported by de Beck (Fig. 259). 


Fig. 259.— Forms of corectopia. (De Beck.) 

The figure at the left shows granular opacity and blood-vessels on the lens. 








Polycoria does not exist in the sense of two or more pupils, each pro¬ 
vided with a sphincter, but the term is applied to supernumerary openings 
in the iris. They are to be explained as gaps occurring from some cause 
during the development of the eye. Not infrequently, in coloboma of the 
iris, a band of tissues will be found stretching across the opening, dividing 
the pupil into two parts. 




376 


MODERN OPHTHALMOLOGY. 


Aniridia.—Cases supposed to present complete absence of the iris are 
occasionally seen. The pupil is all black by daylight and all red to the 
ophthalmoscope. Clinically there is absence of the iris, but dissection and 
microscopic study of such eyes generally show the presence of the remains 
of a rudimentary iris. The condition is generally bilateral, and is asso¬ 
ciated with other congenital anomalies. When aniridia is complete, the 
entire lens can be seen; when incomplete, the iris is absent at certain points 
and only segments of the lens are visible. Aniridic eyes are particularly 
prone to the development of cataract. Vision is often much reduced by 
dazzling. The wearing of dark glasses is advisable. 

Heterochromia is present when one iris presents from infancy a color 
different from that of the other. It may be symmetrical, or one part of 
the iris may be markedly darker than the remainder. Small pigment-spots 
in the iris may be mistaken for foreign bodies by an inexperienced examiner. 

Exfoliation of the Iris is a rare condition. Although not congenital, 
it will be considered here. The process of exfoliation involves the anterior 
layer of the iris. In a case described by Jackson each iris was divisible into 
two zones: an upper, where the color was blue-gray, such as is seen in early 



Fig. 2(30.—Polycoria. (De Beck.) 


infancy; and a lower, which presented a gray-brown color, the stroma of 
the iris being seen indistinctly. Between the zones was an irregular strip 
in which the anterior layer of the iris was hanging in shreds. It is sup¬ 
posed that the change in color in this affection is always from brown to 
blue or gray. Such eyes are said to be particularly liable to cataract. 

Melanoma is a congenital proliferation of the pigment-cells of the iris- 
stroma, forming a small, dark growth which is of interest by reason of the 
fact that it may be the starting-point of a melanotic sarcoma. The condi¬ 
tion is of rare occurrence. 

Ectropion of the Uvea is the name applied to that congenital condition 
in which chocolate-brown masses, composed of from one to ten nodules, 
project from the margin of the pupil on to the margin of the iris. They 
are composed of uveal pigment, which may become detached and float in 
the aqueous humor. The affection has been incorrectly called papilloma of 
the iris. It is common in the horse. 

Albinism.—A congenital absence of pigment often obtains in the en¬ 
tire uveal tract, as well as in other parts of the body. The condition 
has been seen in black as well as in white races. The cause of albinism 


DISEASES OF THE IRIS. 


3 rvrv 

i l 

is unknown. The reason of the failure of the epiblast to form pigment- 
cells is unexplained. Heredity seems to play little, if any, part in the 
etiology of this anomaly. The mental and physical condition of albinos 
compares favorably with that of other persons. According to Gould, the 
pathologic significance of albinism lies in the fact that the iris is trans¬ 
parent, lack of pigmentation in the chorioid having little pathologic sig¬ 
nificance except as permitting trans-scleral illumination. Lack of pigment 
causes the irides to look red; there is photophobia, dazzling, and diminu¬ 
tion of vision. Often there is nystagmus. Astigmatism is frequently 
present and is due in large measure to the pressure of the eyelids (in a state 
of blepharospasm) upon the globe, the facial muscles also co-operating. 
Amblyopia is often present in these cases, and strabismus or muscular 
insufficiency also occurs. Ophthalmoscopic examination usually shows the 
fundus entirely normal, except for the absence of pigment. The treatment 
of albinism includes the correction of ametropia and the use of dark glasses. 

Congenital Tumors of the Iris are cysts and nasvi pigmentosi. Little 
is known of them. The cysts are mentioned elsewhere in this chapter. 

Congenital Atrophy of the Iris is a rare condition which is due to 
intra-uterine inflammation. 



Fig. 261.—Cyst of the iris. (Collins.) 


The cyst is situated between the two layers of pigment at the back of the iris. 

Adhesion of the Iris to the Cornea is a rare anomaly which is usually 
present in the form of a union between the peripheric portions of these tis¬ 
sues, the central portion of the anterior chamber being, as a rule, of normal 
depth. Failure of the iris to separate completely from the cornea interferes 
with the drainage of the aqueous humor and is a cause of infantile 
glaucoma. , 


TUMORS OF THE IRIS. 

Cysts of the Iris.—These are divisible into serous, or true cysts: epi¬ 
thelial, or implantation cysts, due to the implantation of foreign tissues; 
dermoid cysts, and entozoal cysts. The true (endothelial) cysts may be 
congenital or acquired. When congenital they must be accounted for by 
assuming that a crypt of the iris becomes closed and fluid collects in it. 
Acquired cysts are nearly all due to trauma, although some are undoubtedly 
caused by glaucomatous processes. This is particularly true of the cysts 
situated between the two layers of pigment epithelium on the back of the 
iris (Fig. 261). Of the implantation cysts much has been written. They 
may follow a cataract extraction, or any* corneal wound which drags epitlie- 


378 


MODERN OPHTHALMOLOGY. 


lium or hairs into the anterior chamber. These tumors present a mother- 
of-pearl appearance due to cholesterin crystals. They have been called pearl- 
cysts or cholesteatomata. They contain a lining of laminated epithelium 
and semisolid contents, consisting of degenerated epithelial ceils and fat- 
globules. Epithelial cells or hair-bulbs transported to the anterior chamber 
find favorable soil for growth. They may remain quiet for a long time and 
then become active. When they grow", the eye becomes painful, the tension 
rises, and a large part of the anterior chamber is filled by the cyst. Unless 
removed early, the growth may cause iritis, iridocyclitis, secondary glau¬ 
coma, or sympathetic ophthalmitis. As might be expected, these cysts can 
be produced experimentally in the lower animals. 

A few cases of congenital dermoid cyst have been reported. Monzon 
mentions two and Snell, of Rochester, has observed one. The entozoal cysts 
are chiefly caused by the cysticercus. A few have been caused by the filaria. 

Diagnosis. —The diagnosis of cyst of the iris can be made by inspec¬ 
tion. The history with reference to trauma should be carefully elicited. 



Fig. 262 .—Serous cyst of the iris following discission for milky cataract. 

(Ayres.) 

Treatment. —The treatment is early and radical removal. A large 
incision should be made in the cornea with a von Graefe knife, and the part 
of the iris containing the cyst should be drawn out and excised. The re¬ 
moval must be thorough, otherwise the cyst will recur. Under favorable 
circumstances vision may be saved. If the eye is already blind, the cyst 
large, and particularly if the eye is tender to the touch, an enucleation or 
one of its substitutes will be necessary. 

Sarcoma of the Iris.—Of the different portions of the uveal tract, the 
iris is most rarely the seat of primary sarcoma. Most of the reported cases 
were melanosarcomata arising from nrevi pigmentosi in persons past the 
thirtieth year, although the disease has been observed as early as the second 
year by Alt and as late as the seventy-fifth year by Zellweger. In about 
25 per cent, of the cases the growth is a lymphosarcoma. The tumor con¬ 
sists usually of spindle cells, some pigmented, others not, arising chiefly 
from the anterior layers of the iris. It increases by growth of the stroma 
or adventitia cells, fills the anterior chamber, and involves the ciliary body. 
The most noticeable of the early symptoms is the presence of a growing 
tumor, which is usually pigmented. It may exist for months or even years 


DISEASES OF THE IRIS. 


379 


before causing inflammatory symptoms, or before interfering with the move¬ 
ments of the iris. The tumor is often vascular and nodular. It may cause 
hemorrhages into the anterior chamber. The lens becomes displaced, the 
tension increased, iritis develops, and the eye becomes blind. These growths 
are said by Iverschbaumer not to pierce the corneoscleral region often, thus 
differing from tubercle of the iris. 

Diagnosis.— Sarcoma of the iris may be mistaken for simple melanoma, 
gumma, or tubercle. The symptoms have been carefully studied by Veasey, 
who collected forty-six undoubted cases of sarcoma. From Veasev’s article 
and other sources the author has constructed the following table:— 


Melanoma. 

Becomes darker and 
darker. 

Is congenital. 

No specific history. 


Antisyphilitic treat¬ 
ment does not in¬ 
fluence it. 

Is stationary. 


Gumma. 

When a gumma appears 
there is severe iritis. 

History and symptoms 
of syphilis. 

Color : iron-red or deep 
yellowish red. 


Non-vascular. 

Antisyphilitic treat¬ 
ment removes it. 


Is generally situated 
peripherally. 
Hypopyon may be 
present. 


Tubercle. 


Appears usually in per¬ 
sons under twenty. 

Tubercular foci often 
found elsewhere. 

Inflammatory symp¬ 
toms appear early. 

Color: yellowish white, 
light grayish white, 
or light grayish yel¬ 
low. 

Non-vascular, as a rule. 

Irregular in form. 


Is of rapid growth. 

Is generally situated 
near the pupil. 
Hypopyon may be 
present. 


Melanosarcoma. 
Retains its primary 
shades usually. 

Is not congenital. 


No inflammatory symp¬ 
toms in early stage. 

Color: reddish gray, 
blackish, light brown, 
or flesh-color. 

Is vascular. 

Rounded in form. 

Antisyphilitic treat¬ 
ment does not in¬ 
fluence it. 

Grows slowly. 

May have multiple 
points of growth. 


Treatment. —In view of the difficulties attending the diagnosis of 
iridal growths, it will be advisable to operate upon them early, making a 
broad iridectomy which shall include all of the mass and a part of the 
healthy iris on each side. Then a microscopic examination can be made and 
the nature of the growth determined. If it proves to be a sarcoma, the 
question of enucleating the eye must be considered, although it will be 
advisable to wait for a time and to note the effect of the iridectomy. In 
a few cases not only has the eyeball been saved and useful vision preserved, 
but no recurrence has been noted for years after the operation. The growth 
of an iris sarcoma is slow, and a period of at least three years must elapse 
before a case treated by iridectomy can be considered as cured. If vision 
is seriously affected, an immediate enucleation should be performed. If, 
after iridectomy, the growth shows signs of recurrence, the eye must be re¬ 
moved immediately. Cases of sarcoma of the iris cured by iridectomy have 
been reported by Arlt, Kipp, Knapp, Veasey, and others. On the other 
hand, it may be impossible to determine whether the ciliary body is involved. 
Wood and Pusey, who have given the latest contribution on this subject, 
hold that an enucleation should be made as soon as the diagnosis, of iris 
sarcoma has been established. 





380 


MODERN OPHTHALMOLOGY. 


Vascular Tumors of the Iris.—These have been seen a few times as 
dark, lobulated growths, springing from the iris and bleeding spontaneously. 
In some cases they are associated with multiple nevi scattered over the 
whole body. Vascular iridal tumors are likely to be mistaken for sarcomata. 
They should be removed by making a broad iridectomy. 

Unusual Tumors of the Iris.—In addition to the growths already de¬ 
scribed, the iris is in rare cases the seat of myomata, myosarcomata, lympho¬ 
mata, and of certain epithelial formations resembling carcinomata. The 
nature of these growths can be determined after removal. Lymphomata are 
found in cases of splenic leukemia. The growths may be situated deeply or 
superficially in the iris-tissue. When superficial, they are present as multi¬ 
ple gray, transparent nodules surrounded by a vascular network. When 
deeply placed they cannot be seen, but their presence should be suspected 
because of chronic iritis with pupillary exudate and vitreous opacities. Un¬ 
like tubercles, lymphomata of the iris do not suppurate. They may be 
confounded with gummata. The disease is found chiefly in young persons, 
and, according to Horner and von Michel, it precedes the general mani- 



Fig. 263.—Cysticereus which has broken through an iridal vessel. 

(Ivraemer.) 


festations of leukemia. Microscopic examination shows a mass of leuco¬ 
cytes in the stroma of the iris, which is more dense than normal and presents 
vessels gorged with white corpuscles. In benign forms the neoplasm may 
entirely disappear, leaving the iris partially discolored and atrophic, while 
grave cases end in total atrophy of the globe. Aside from the use of atropin, 
local treatment is not indicated in these cases. 

leprosy of the Iris.—According to Neve, the iris is often attacked in 
ocular leprosy, especially where the infiltration has begun in the corneal 
margin. Nodules form in the iris-angle, partially obliterating the anterior 
chamber. Less often a single nodule is present, but seldom is on or near 
the edge of the iris. The whole iris-tissue becomes softened by a chronic 
inflammatory process. There is a deposit of fibrin which occludes the pupil. 

.Tubercle of the Iris—When tuberculosis of the iris (Fig. 3, Plate XII) 
assumes the solitary form, iritis may be absent for a considerable time. Such 
cases were described by von Graefe under the name granuloma of the iris. 
The tubercular nature of such growths was first demonstrated by Haab. The 
differentiation between this disease, gummatous iritis, and sarcoma may be 
difficult. Tubercle is generally found between the fourth and twenty-first 


DISEASES OF THE IRIS. 


381 


years, while sarcoma usually appears later in life. The history of the case 
and the finding of tubercular foci elsewhere will aid in diagnosis. Tubercle 
is of more rapid growth than sarcoma (Andrews). In any case of solitary 
mass in the iris antisyphilitic treatment should be instituted. If it fails, 
the mass should be excised by iridectomy and examined microscopically and 
by inoculation experiments on rabbits or guinea-pigs. If the entire mass 
cannot be removed, an enucleation should be made, and in all cases of 
multiple growths the eye should be excised (Bull). Internal treatment 
with creosote, and injections of tuberculin, may be tried in the early stages 
of iridal tuberculosis before resorting to enucleation. Ivoster has recently 
reported cures from the injection of air into the anterior chamber. The 
chamber is first partly emptied; air is then injected through a Pravaz syr¬ 
inge. Patients with tubercular iritis often die from tubercular meningitis. 

Cysticercus.—The parasite appears in the anterior chamber as a round, 
whitish, grayish, or yellowish mass, about one millimetre in diameter. At 
one particular part of the cyst a whitish projection is noticed which changes 
its shape from time to time. The mass may be found in the bottom of the 
anterior chamber or it may float free in the aqueous. At the time it breaks 
forth from an iris vessel there is great pain. The parasite should be re¬ 
moved through an incision made in the cornea. 

Filaria. — The filaria has occasionally been found in the anterior 
chamber or iris of persons living in the Orient or in Africa. The disease 
is not seen in England and America except by importation. 


INFLAMMATION OF THE IRIS. 

Iritis is an inflammation of the iris. It may be congenital or acquired, 
idiopathic or traumatic, primary or secondary, acute or chronic, simple or 
complicated. Since the iris and ciliary body receive the same blood-supply, 
both are usually involved in inflammation simultaneously. For many 
reasons, however, it is advisable to consider their diseases separately. Iritis 
is a subject of the greatest importance to the patient, to the general practi¬ 
tioner, and to the ophthalmologist. Recognition of the disease and proper 
treatment will give satisfactory results. Unfortunately, however, mistakes 
in diagnosis often occur, and in consequence the patient becomes partly or 
entirely blind. 

Symptoms. —In idiopathic iritis the subjective signs are pain, photo¬ 
phobia, and loss of vision. The objective signs are lacrimation, congestion 
of the corneoscleral zone, immobility or sluggishness of the contracted iris; 
change in its color, thickness, and form; and, under a mydriatic, the pres¬ 
ence of adhesions. These either bind the iris to the capsule of the lens pos¬ 
teriorly, making the pupil irregular in form, or to the cornea in front. 
Under mydriasis the pupil may be round, in which case careful examination 
will show deposits of pigment on the lens-capsule. Pain in iritis is referred 
to the eye, the nerve-exits around the orbit, the temple, or, as will often be 


3S2 


MODERN OPHTHALMOLOGY. 


found, to the side of the nose along the course of the nasal nerve. Pain 
in iritis is often worse at night or in the early morning. It may he entirely 
absent, or may be so excruciating that the patient is clamorous for relief. 
The eye is tender on pressure, particularly at a point mentioned by Callan, 
about two millimetres behind the corneoscleral junction, under the middle 
of the upper lid. Loss of vision is great in those forms of iritis in which 
the aqueous humor becomes turbid or where exudation into the pupillary 
area is considerable. Accommodative power is also impaired. 

On inspection, the iris is seen to have a muddy look, its lustre is absent, 
and its tissue appears swollen. Often the distended minor arterial circle will 
surround the pupil like a ring. The change in color, due to hyperemia and 



Tig. >04. —Pericorneal injection in iritis. (Author.) 

(Original drawing by Dr. R. W. Mills.) 

inflammatory products, causes a blue iris to appear greenish and a brown 
one to look jellowish. The pupil is small, and reacts to light slowly or not 
at all. The zone of redness around the cornea is deeply seated, as in any 
serious inflammation of the anterior segment of the globe. There is photo¬ 
phobia and abundant lacrimation. If these symptoms are present, and the 
tension of the eye is not increased, the practitioner will be justified in the 
use of a mydriatic. A 1-per-cent, strength solution of atropin or a solution 
of scopolamin of the strength of V 5 of 1 per cent, is to be used. Half an 
hour after dropping the solution into the eye the pupil will appear dilated ir¬ 
regularly, if adhesions between the iris and lens-capsule are too strong to be 
broken by the mydriatic; or, as often occurs early in the disease, the pupil 



DISEASES OF THE IRIS. 


383 


will be round, and light concentrated on the lens by a glass will show 
minute pigment-spots marking the site of the ruptured adhesions. After 
a slight iritis these spots will he found, since the posterior layer of the iris 
is the pigment layer. Inspection of the anterior chamber may show a turbid 
aqueous; the cornea may he steamy. 

Diagnosis. —Iritis is often mistaken for acute catarrhal conjunctivitis. 
The diagnosis can he made by attention to the following points: Conjunc¬ 
tivitis presents a discharge; uncomplicated iritis does not, but generally 
in iritis there is an accompanying conjunctivitis. In conjunctivitis the 
greatest redness is situated posteriorly, where the ocular and palpebral parts 
of the conjunctiva join; in iritis the greatest redness is around the corneo¬ 
scleral junction. The redness of iritis is more deeply placed than is that 
of conjunctivitis. The injected conjunctival vessels are distinctly seen, 
while the deeper vessels of the circumcorneal zone present a deep, diffuse- 
red color. 

The iris in conjunctivitis responds to light. In early iritis it responds 
sluggishly, if at all; more often it is immobile and contracted. Vision is 

Co J " ' 



Fig. 265.—Different appearances of the pupil in iritis, after the use 

of atropin. 


1 , Three adhesions. 2, Pupil dilated regularly, with pigment-dots on the anterior cap¬ 
sule of the lens. 3 , One adhesion. 4, Multiple adhesions with little dilation. 5. Adhesions 
at four points and pigment-dots showing where the mydriatic has broken up an adhesion. 


not affected in conjunctivitis, barring the spreading of mucus over the 
cornea, the existence of a complicating keratitis, or the presence of a cor¬ 
neal scar; in iritis vision is usually much reduced from turbidity of the 
aqueous humor or from exudation on the lens. The tension of the eye is not 
changed in conjunctivitis; in iritis there is occasionally increase of tension 
in the height of the 'disease. The color and lustre of the iris are not 
changed in conjunctivitis; in iritis the iris looks muddy, has lost its bright 
appearance, and is often changed in color. In conjunctivitis the pupil 
dilates regularly after the use of a mydriatic; in iritis the pupil may dilate 
regularly or irregularly, due to causes explained above. 

Differentiation between Iritis and Glaucoma .—It might be supposed 
that diseases as unlike as iritis and glaucoma should not be confounded, 
but it often occurs that the practitioner considers a case of acute inflam¬ 
matory glaucoma to be iritis, and treats the glaucoma with atropin—the 
worst possible treatment. Both diseases reduce vision and present pain as 
a prominent symptom. The following table gives the points in differential 
diagnosis:—• 












384 


MODERN OPHTHALMOLOGY. 


Iritis. 

The pupil is small. 

Usually the patient is under forty-five 
years of age. 

Tension may increase in the height of 
the disease. 

The anterior chamber is of normal 
depth except in neglected cases with 
complete annular synechia; in these 
it is deeper than normal. 

The cornea is sensitive to the touch. 

The ophthalmoscope cannot be used 
with satisfaction. 

The chief causes of iritis are trauma, 
syphilis, rheumatism, and gonorrhea. 


The refraction has no etiologic bearing. 


Glaucoma. 

The pupil is dilated. 

Usually the patient is over middle age. 

Tension is increased, either intermit¬ 
tently or permanently. 

The anterior chamber is shallow. 


The cornea is anesthetic. 

The ophthalmoscope often will show ex¬ 
cavation of the head of the optic 
nerve and pulsation in the retinal 
arteries. 

The causes of glaucoma are numerous, 
including closure of the iris-angle, 
trauma, intra-ocular growths, and 
certain conditions of the blood and 
blood-vessels. 

Refraction generally is hypermetropic. 


Differentiation between Iritis and Cyclitis. —While pathologic study 
shows involvement of the ciliary body in nearly all cases clinically diag¬ 
nosticated as iritis, it is not customary to speak of the condition as a cyclitis 
or an iridocyclitis unless certain symptoms are present. These include: 
(1) edema of the upper eyelid, which is not present in simple iritis; (2) 
alteration of intra-ocular tension, which may be increased or diminished; 
(3) the presence of considerable pain or tenderness when pressure is made 
in the region of the ciliary body; (4) the presence of deposits on Descemet’s 
membrane; (5) greater loss of vision than can be accounted for by the 
muddiness of the aqueous humor. 

Varieties of Iritis. —Having made a diagnosis of iritis, it will be 
in order to determine which variety of the disease is present: serous, plastic, 
or parenchymatous. 

Serous Iritis (Fig. 1, Plate XII), so called, is characterized by a deep 
anterior chamber, the presence of deposits in the aqueous and on the back of 
the cornea, and a mildness of the subjective symptoms. This disease may 
be caused by syphilis. It is the form of iritis often found in sympathetic 
ophthalmitis. Often the pupil is dilated and the tension of the eye is in¬ 
creased by physical and chemic changes in the aqueous, thus simulating 
glaucoma. Inasmuch as this disease has been shown by recent pathologic 
studies to depend on alterations in the glands of the ciliary body, it will be 
further discussed under the name “Serous Cyclitis.” 

Plastic Iritis is the type of iridal inflammation which is most frequently 
encountered. It is called plastic from its tendency to form adhesions be¬ 
tween the iris and crystalline lens, and to occlude the pupil. It may run an 
acute, subacute, or chronic course. It presents the classic symptoms of 
iridal inflammation: pain; pericorneal injection; immobility of the iris, 






PLATE XII, 

ExtBrnal EisBasas of the Eya, 



Fig, 2. 

Gummatons Iritis, 

'? ' •T'> A • ■ . . V 


Fig, 3, 

Tuberculosis af tlia Iri3, 
(Andrews,) 


Fig. 4. 

Melanosarcoma af tils Chariaid. 


Fig. S, 

Absolute Glaucoma. Rupture of the Sclera with Escape 

of the Lens. (After Sichel.) 


Fig. 2. 

Neuroepithelioma of tha Retina. 


Fig, a. 

Pseudo-nauro epithelioma 
of thB Ratina. 


















.11 x 

evot axil in as ae Beta Ia'm:fetxa[ 






.'idle age. 








‘ her, .eyniit- 

r situllow. 


S. .$ iT 

•sitril sxiati3.tTL£H£fC] 


.X sn 

.sJIHI zuoi.iS 


• ill -hi, ;> cX- 

Mmst optics 
i retinal 


numercti-, 
i.V nn-tmgle, 
ami 
34 nrui 


The rcfir&i: . 


■ topic. 




■ £ ’fifX ,e ,gn " 

rif.ttoi'tX' sat! atnontaann^sM .b!s£ axit to EXecIinTarff/T’- 

,, h&wcra-iiiiiA.) 






ijiioms are pr 
j? rot pr*n-. iv 
■ may be . < 

’ 111 o f tenderness • 




f • 


: ' e p rest? in e <■ 


t than cm? m 




3 .fir? 

“ !!w 'se; j 2 art} Id a«i%x.K 
f -ad'iicr taftR) sxiaJ adi tj 


. !* a liiesxnrw. 
t] AQtiie is r.i 


be 
■ 11 o. 


- ■ calico, j$ ch 

\ iitpi... 


,e ,?n' 

,£xnDa£r£l3 a mlt ad'.rx 
•feerj 


. e s mntovu ■ 


i :r"f a 


iritis often bin?! 

"t mid the tension . 
a in the aqueous, i 
- -a.- boon sjhowu hv r< i< 


■uck of 
may 

’i-etic 
in- 


; ot mg 


-B, c-.n 

BinntlBiittrjF! o j Ufja . oftiJSB q ; 
■xfiiitaK a'di la 


■■ glands of the ciliary Uh 


. (>C!C 




■ ius Cyclitis/’ 

•!■■■ its tendency to form adi: ■ •; • 

'<) occlude the pupil. It ma a 

' presents the classic syn.t-. ■ of 
;■ injection; immobility of rh* :rii, 




















PLATE 12 








DISEASES OF THE IRIS. 


385 


which is discolored; and posterior synechiae. Aside from the. ordinary at¬ 
tachments existing between the iris and lens, plastic iritis may result in 
the pouring of an exudation into the anterior chamber, filling the pupillary 
area with a gelatin-like mass (fibrinous, or spongy, iritis). Syphilis is a 
frequent cause of plastic iritis, the involvement of the iris occurring gen¬ 
erally between the second and ninth months after the appearance of chancre. 
Exceptionally iritis in a syphilitic subject may be delayed till the eighteenth 
month. Both eyes are generally involved, but usually not at the same time. 
Rheumatism is a frequent cause of plastic iritis. 



Fig. 266.—Gummatous iritis. (Author.) 

(Original drawing by Dit. R W. Mills.) 

Parenchymatous Iritis is divisible into suppurative, gummatous, and 
tubercular forms. In all forms of parenchymatous inflammation the iris 
is much thickened and distorted. 

In suppurative iritis pus-cells are present in the tissue of the iris, and 
hypopyon is common. The most frequent cause of-suppurative iritis is in¬ 
fection by a wound. The hypopyon of the idiopathic form of suppurative 
iritis disappears rapidly, since it consists only of pus-cells, and is not mixed 
with fibrin as is the hypopyon of ulcus serpens corneas (Fick). Diabetes 
and acute infectious diseases, such as pneumonia, cerebro-spinal fever, 
influenza, etc., are causes of suppurative iritis. It also occurs from em¬ 
bolism in puerperal septicemia and pyemia. 


38 6 


MODERN OPHTHALMOLOGY. 


Gummatous Inflammation of the Iris (Fig- 2, Plate XII) appears in the 
later secondar}^ stage of syphilis, and presents clinical signs peculiar to itself. 
In rare instances it is found in infants with hereditary syphilis. The iris 
shows one or more yellowish-brown or reddish-brown nodules, varying in 
size from a pin’s head to a pea. They are found in the ciliary or pupillary 
border or midway between the two, and are often crossed by vessels. Al¬ 
though found in the secondary stage of syphilis, the name gummata has been 
applied to them. They soon disappear under treatment without leaving 
scars in the iris-tissue. Some authors apply the term iritis papulosa to this 
condition, and reserve the name gummatous iritis to those cases of true gum¬ 
mata which appear later in the history of syphilis. 

Tubercular Iritis is due to the development of the tubercle bacillus in 
the iris. It is secondary to a tubercular focus located in another part of 
the body, and is found principally in persons under twenty years of age. 
Direct tubercular infection of the iris can occur only through a wound. In 


| 

Fig. 267.— Iritis with hypopyon and chemosis. (Von Ammon.) 

The pupil is irregular. The collection of pus reaches to the lower part of the pupil 
The chemotic conjunctiva forms a ring around the cornea. The vessels of the conjunctiva 
are much enlarged, 

this form of iritis small, gray, transparent nodules are seen which slowly 
change, some disappearing while others form. The disease is often bilateral. 
Recovery may take place, but the eye is generally lost by tubercular irido¬ 
cyclitis. The solitary tubercle of the iris has been described with the tumors 
of this part. 

Pathology.— Iritis causes various changes in the eye according to 
(a) the nature of the inflammation and (b) the duration and treatment. 
In the simple plastic form an exudation of fibrin takes place into the tissue 
of the iris itself, and into the anterior and posterior chambers. A few pus- 
cells are found in the exudate. The aqueous humor is made muddy by the 
exudate and the pupil appears grayish in consequence. The particles of 
exudate are deposited in the bottom of the anterior chamber and form an 
hypopyon. If the hyperemia is great, some of the vessels rupture and the 
blood also sinks to the bottom. A layer of exudate is also found on the 
anterior surface of the iris, giving it a blurred appearance. This layer may 
glue the iris to the back of the cornea, as shown in Fig. 268, or, as more 








DISEASES OF THE IRIS. 


387 


often happens, it simply fills up the pupil (occlusion of the pupil), obstructs 
vision, and leads to the formation of opacity in the lens. Exudation into 
the posterior chamber causes adhesions (posterior synechige) between the 
iris and the anterior capsule of the lens. The adhesions develop chiefly 
at the pupillary margin, the point where normally the iris and capsule are 
separated by a very thin water-bed. It may happen that the exudate oc¬ 
cupies the whole space between the iris and the lens, thus making a complete 
posterior adhesion. In the formation of adhesions, it is not the iris-stroma, 
but the pigment layer, which becomes attached to the lens. In response to 
a mydriatic the iris is drawn toward the periphery, exposing the pigment. 
If the adhesions are completely severed, a round -pupil results, and pigment- 
spots remain on the anterior capsule. In case the whole pupillary margin 



Eig. 268.—Anteroposterior section of an eye which shows post-iritic glau¬ 
coma, calcareous cataract, and chorioiditis. (Author.) 

These changes were all caused by a neglected iritis. In the fresh specimen the iris, 
through a large part of its extent, was adherent to the posterior surface of the cornea, from 
which it has been separated in order the better to show the annular posterior synechia. 


of the iris becomes adherent (annular posterior synechia), the posterior 
is completely shut off from the anterior chamber. Thus, the passage of 
aqueous humor into the front of the eye is stopped and the iris becomes 
bulged forward (iris bombe ), producing the condition known as post-iritic 
glaucoma. If the process is not checked by an excision of part of the iris, 
all of the tissues of the eyeball become involved, the optic-nerve head under¬ 
goes excavation, and vision is destroyed. 

During an attack of iritis many other tissues suffer. The cornea is 
involved in every case (Friedenwald), being more or less opaque owing to 
infiltrations in the substantia propria or to deposits on Descemet’s mem¬ 
brane. In many instances the corneal opacity can be detected only by 
careful examination. Iridocyclitis, iridochorioiditis, hyalitis, and neuro¬ 
retinitis are frequent complications. As a result of frequent attacks of 


388 


MODERN OPHTHALMOLOGY. 


acute iritis, or from a long-continued chronic state, the iris becomes atrophic. 
It has a bleached appearance, the normal delicate markings are lost, and the 
pupillary margin looks frayed. 

Etiology. —Iritis may be the result of trauma, but generally it is due 
to a constitutional vice. Syphilis causes about 50 per cent, of the cases. 
Rheumatism is another frequent factor, producing about 30 per cent. Other 
causes are anemia, malaria, diabetes, gonorrhea, gout, neoplasms, and acute 
febrile diseases. Diabetic iritis is one of the rarest forms. Sympathetic 
ophthalmitis causes the form of iritic and cyclitic inflammation which will 
be described as “Serous Cyclitis.” In many cases of iritis it is impossible 
to determine the cause, since there is no constant symptom by which to 
recognize the diathesis present. If syphilis always produced the charac¬ 
teristic nodules in the iris, recognition would be easy; but many cases 
undoubtedly due to syphilis do not present symptoms and exudation dif¬ 
ferent from those which are found in rheumatic iritis. Rheumatic iritis has 
long been credited with a marked tendency to recurrences, but it is not cer¬ 
tain that this statement will bear investigation. 

Iritis occurs chiefly in young adults and in middle-aged persons. In 
children it rarely occurs, and is then due usually to hereditary syphilis, or 
tuberculosis, or exists as a complication of corneal ulcer. In proof of the 
rarity of iritis in syphilitic infants it may be stated that George Carpenter, of 
London, although he has examined the eyes of hundreds of such subjects, 
never saw an undoubted case: i.e., one with irregular pupil under atropin; 
and Jonathan Hutchinson, Sr., records only twenty-three cases. Of Hutch¬ 
inson's cases, the youngest was six weeks, the oldest sixteen months of age. 
Iritis is sometimes found in young girls at the period of puberty. 

Traumatic iritis may arise from blows, operative procedures, pene¬ 
trating wounds, or the lodgment of foreign bodies. It may be plastic or 
purulent; if the latter, it is a part of panophthalmitis. Perforating corneal 
ulcers also cause iritis. An extremely severe and long-continued inflam¬ 
mation of the iris follows the penetration of the hairs of the caterpillar into 
the conjunctiva, cornea, and iris, producing the condition known as oph¬ 
thalmia nodosa. This form of ocular inflammation has been described in 
the chapter on the conjunctiva. 

It is because of the impossibility of founding a classification of iritis 
on the etiology that the author has adhered to the old division into serous, 
plastic, and parenchymatous forms. 

Congenital Iritis , as shown by the presence of congenital posterior 
synechia;, has been observed by Bull in infants within two hours after birth. 
The disease is to be attributed to syphilis, and this opinion is confirmed 
by the occurrence of “snuffles” within a few weeks after birth, and by the 
finding of mucous patches around the anus. Owing to the absence of 
ciliary injection and the infrequent occurrence of discoloration of the iris, 
iridal inflammation in infants may be overlooked. In fact, it can generally 
be detected only by the use of atropin and oblique illumination. 


DISEASES OF THE IRIS. 


389 


Diabetic Iritis is a rare form of ocular disease. Galezowski met with 
it 7 times among 144 diabetic patients with ocular diseases. Leber saw it 
9 times among 39 diabetics. This type of iritis is often purulent, and a 
noteworthy fact is the rarity of purulent iritis without the coexistence of 
purulent keratitis. The iridal inflammation is rarely of a severe grade, and 
hypopyon, when present, is usually small. The pupillary space is likely 
to be filled with a fibrinous membrane, which disappears rapidly under 
appropriate treatment. Occasionally the disease assumes the serous type. 
While the course of diabetic iritis is generally favorable, there may be com¬ 
plications, such as cyclitis, chorioiditis, cataract, and opacities in the vitreous 
body. Iritis, following the operation of iridectomy, is not infrequent in 



Fig. 269.—Proliferation of the pigment layer of the iris in 
diabetes. (Author.) 

(Photomicrograph by Dr. II. P. Wells.) 

diabetics. Microscopic examination has shown the frequent occurrence of 
changes in the pigment-epithelium layer of the iris, ciliary body, and 
retina. They include a loosening, proliferation, and probably edematous 
swelling of the pigment-cell layer on the posterior surface of the iris. 
Hence, following an operation such as iridectomy or cataract extraction, 
the aqueous humor may appear black from pigment held in suspension. 
Cases of diabetic iritis require treatment for the constitutional condition 
in addition to the usual local remedies. 

Senile Iritis. —In elderly persons it is not unusual to find that iritis 
is overlooked by the medical attendant because of absence of the common 
signs. There may have been an acute catarrhal conjunctivitis involving 
both eyes. After the application of the usual treatment one eye recovers 



390 


MODERN OPHTHALMOLOGY. 


and the other does not. Inspection shows no muddiness of the iris or 
aqueous humor, the pupil responds to light, tension is normal, pain is 
slight, and perhaps the only sign of iritis is a slight pinkish redness around 
the cornea. After excluding glaucoma by ophthalmoscopic examination, 
the surgeon should dilate the pupil ad maximum with atropin. Then the 
presence of adhesions, either at the pupillary margin or more frequently at 
the peripheral part of the iris, will declare the true condition. Continued 
use of a mydriatic will cure these cases. During the treatment the tension 
should be watched. Hale has called attention to two signs of diagnostic 
value in these cases of quiet iritis: (a) one eye is usually involved more 
than the other and (b) the muco-purulent discharge characteristic of con¬ 
junctivitis disappears and is succeeded by profuse lacrimation. The author 
has seen several of these cases which he attributed to malaria. 

Uveite Irienne. —Grandclement has called attention to the importance 
of distinguishing from ordinary iritis those cases in which only the poste¬ 
rior layer of the iris is involved. To these he applies the term uveite irienne. 
In every respect this affection is different from ordinary iritis, and the 
points in differentiation are given in the following table:— 


Uveite Irienne. 

Occurs almost exclusively in women. 

Both eyes are always affected. 

Disease lasts for years and shows slight 
periodic exacerbations, lasting five or 
six days. 

Causes are unknown. 

Only effective treatment is iridectomy. 

No discoloration of anterior surface of 
iris. 

Pain is almost absent and redness is 
slight. 

Occurs about the time of the meno¬ 
pause. 


Iritis. 

Occurs irrespective of sex. 

Often is unilateral. 

Symptoms are violent, and the disease 
is cured in six or eight weeks. 

Causes are trauma and constitutional 
vices. 

Proper treatment is the use of myd- 
riatics. 

Anterior surface of iris is discolored. 

Pain is severe and redness is marked. 


Prognosis of Iritis. —The prognosis will depend on ( a ) the time 
of recognition of the disease, (b) the treatment instituted, and (c) the 
character of the cause. An eye whose iris has been the seat of inflamma¬ 
tion rarely makes a complete recovery, although vision may be retained and 
the eye remain quiet through life. Simple plastic iritis, if recognized early, 
offers a favorable prognosis. The parenchymatous forms, except when due 
to tubercle, usually give fair results. Suppurative iritis generally ends in 
panophthalmitis and the loss of the eye. In serous iritis due to sympathetic 
ophthalmitis the prognosis is very grave. Iritis following ulcers of the 
cornea is a serious condition, and is discussed in the chapter on “Diseases 
of the Cornea.” If seen early and properly treated, the great majority of 
cases of idiopathic iritis will give satisfactory results. The occurrence of 



DISEASES OF THE IRIS. 


391 


a pronounced cyclitis and chorioiditis adds much to the gravity of the 
prognosis. Post-iritic glaucoma is a formidable condition which often 
produces symptoms demanding enucleation of the eye. 

Treatment. —The sovereign remedy for iritis is the strongest myd¬ 
riatic that the patient can bear. A solution of atropin (1-per-cent, strength) 
or of scopolamin ( 1 / 5 of 1 -per-cent, strength) will break up the adhesions 
when used early in the case, and relief of pain and hyperemia will follow 
this treatment. Scopolamin is particularly valuable in the parenchymatous 
and traumatic forms of iridal inflammation. The mydriatic should be used 
three or four times a day for the first week or ten days, after which period 
it will suffice to use it once a day. The manner of making the instillation 
is of importance. The solution should be gently warmed and dropped on 
to the upper middle part of the sclera while the eye is directed downward, 
thus causing the solution to float over the cornea and promoting absorption. 
In delicate nervous individuals, and particularly in females and children, 
care must be taken not to produce the toxic effect of the drug. Of the 
two mydriatics mentioned, scopolamin is the more powerful and the more 
likely to cause toxic symptoms. It is advisable either to compress the 
puncta while using the drops or to have the patient incline his head in 
such a direction that the medicine will flow toward the outer canthus. In 
case the atropin solution causes conjunctivitis, eczema of the lids, and toxic 
symptoms, the alkaloid can be used in the form of an ointment (atropin, 
gr. iv; cocain, gr. vj; vaselin, 53 ), or one of the ophthalmic discs contain¬ 
ing atropin and cocain can be placed under the lower eyelid and be permitted 
to dissolve. The latter method is clean and efficient. 

Darier claims that dionin aids the mydriatic action of atropin, hastens 
absorption of pupillary exudations, diminishes intra-ocular tension, and 
relieves pain. He uses the following collyrium:— 

R Dionin . !....gr. iss. 

Cocain .gr. iss. 

Atropin .gr. ss- 8 / 4 . 

Water .3iiss. 

M. Sig. : One drop to be placed in the affected eye six to eight times a day. 

Unfortunately it often occurs that patients come after adhesions have 
bound the iris to the lens-capsule. An attempt must be made to secure 
dilation of the pupil, and this will necessitate the forced use of mydriatics 
with the simultaneous internal administration of considerable amounts of 
mercury. Absorption of the mydriatic will be facilitated by the previous 
local use of a few drops of adrenalin solution (1 to 5000), or by the em¬ 
ployment of cocain simultaneously with the mydriatic. Then, by dropping 

the scopolamin or atropin solution on to the outer part of the cornea at 
proper intervals, the puncta being compressed and the constitutional symp¬ 
toms carefully watched, the maximum effect' of the mydriatic may be ob- 






392 


modern OPHTHALMOLOGY. 


tamed. Even if full dilation is not secured, there may be sufficient enlarge¬ 
ment of the pupil to permit the normal flow of the aqueous humor. 

The patient's general condition must be carefully studied, and here 
the family physician and the ophthalmologist should work together. It is 
of importance that any constitutional vice should be recognized and treated. 
Search should be made for syphilis, rheumatism, gout, malaria, diabetes, 
and tuberculosis. In diabetic and rheumatic iritis great benefit follows the 
use of large doses of salicylate of sodium. In gummatous iritis huge doses 
of iodid of potassium are often required. Attention should be directed to 
the condition of the intestinal tract. It is a common observation that 
patients with iritis feel much better after the intestinal tract has been 
evacuated. Hot-air baths are of use in hastening the absorption of the 
inflammatorv products. The condition of the nose and throat should be 
investigated. If the patient has a “cold,” or is suffering with chronic 
hypertrophic rhinitis, great benefit will follow the proper treatment of these 
conditions. The patient should be given a pair of dark glasses to protect the 
eyes, and, as soon as the acute symptoms have subsided, should be ordered 
to set out of doors every day. E nder no circumstances should the inflamed 
eye be bandaged, except in traumatic iritis. In case no constitutional 
dyscrasia can be detected, the internal use of laxatives, salines, and mer¬ 
curials will still be beneficial. Often in anemic subjects the administration 
of quinin or A\ arburgs tincture will be ad\antageou&. Stimulants are 
generally out of order in iritis. 

Pain, during the acute period, may call for the internal administration 
of chloral or the hypodermic injection of morphin after the local use of 
dry heat has failed. A convenient method of applying dry heat is the use 
of the Japanese hot box. A valuable remedy for pain is hyoscin (gr. Vioo 
at bedtime). Recently dionin, in 2-per-cent, strength solution, has been 
successfully employed to relieve the pain of iritis. The use of cloths wrung 
out of boiling hot water, applied to the eyelids for a few seconds, is often 
acceptable. The use of leeches, ointments, blisters, poultices, and setons is 
valueless and in some cases is positively harmful. Desmarres s depletion 
— i.e., the section of a subconjunctival vessel, which is permitted to bleed 
freely—often will relieve pain and check the advance of the inflammation. 
If pain is severe and the tension is increased, paracentesis of the anterior 
chamber should be done, removing 2 or 3 drops of aqueous humor. This 
little operation gives relief, and can be repeated every other day until pain 
and tension are diminished. Paracentesis is to be done under holocain 
anesthesia; the puncture is to be made with the von Graefe cataract-knife, 
the back of the blade being placed toward the iris, or the stop-keratome 
can be used. The use of cocain as a routine practice in iritis is not to be 
advised. The mydriatic must be continued until all signs of redness have 
disappeared. It is important that the patient should not apply himself 
to any near work until several weeks after he is entirely well, since too early 
use of the accommodation may cause a recurrence of the inflammation. 


DISEASES OF THE IRIS. 


393 


Tn iritis produced by infectious diseases atropin locally and the proper 
internal treatment must be employed. Often in these rare cases the use 
of quinin and stimulants will be necessary. 

After pain and redness have disappeared the surgeon should note the 
damage done by the disease. If adhesions have shut off the anterior from 
the posterior chamber, an immediate iridectomy should be made. It will 
give a good result provided the ciliary body and retina are intact. In 
recurrent iritis, with numerous adhesions, an iridectomy should be made 
between the attacks and will often prevent recurrences, provided the general 
system is cared for. If the pupil is blocked by exudation interfering with 
vision, an optical iridectomy is of value-. 

Before resorting to an excision of the iris for extensive adhesions fol¬ 
lowing iritis, the surgeon should determine, as far as possible, the condition 
of the deep parts of the eye, the acuity of vision, the effect of mydriatics 
upon the iris, and the condition of this membrane. If the iris is atrophic 
or the vision is greatly reduced, the effect of an iridectomy will be slight 
or nil. The excision of an atrophic iris is a difficult matter. If the tension 
of the eye is subnormal, it is probable that no good will follow the iridec- 
tomv. On the other’hand, increased tension remaining; after recovery from 
acute iritis renders iridectomy imperative, and here the operation is often 
followed by brilliant results. When only the pupillary margin is attached, 
an iridectomy can be made easily; while if the whole iris is bound down 
to the capsule, the excision is difficult. After completing the operation the 
surgeon may find that he has removed onty the anterior layers of the iris, 
while the pigment layer remains attached to the capsule. In such cases it 
is often necessary to extract the lens, together with a large part of the iris, 
to get results. Even under the most skillful manipulation some of these 
cases will go to destruction, either by hemorrhage during or following the 
operation, by infection, or by iridocyclitis. 

Where only few posterior synechias are present, they do not call for 
treatment. It has been held that their presence tends to produce relapses; 
this, however, is doubtful, since every ophthalmic surgeon has met with 
patients presenting extensive posterior synechias, who for many years re¬ 
mained free from a second attack of iritis. 

The operation for detaching such adhesions (corelysis), so often prac¬ 
ticed by the older ophthalmologists, is now obsolete. The condition of the 
refraction after iritis demands attention. During the attack the emmetropic 
eye becomes myopic, the hypermetropic less so, and the myopic eye more 
myopic. This condition gradually disappears and the refraction returns to 
its original state. On account of the existence of this transient myopia it 
will be advisable to test the refraction several times during the year follow¬ 
ing recoverv from iritis. 

Treatment of Uveite.— In the form of inflammation which Grand- 
clement has described under the name uveite irienne atropin is of little 
value. Such cases should be treated by iridectomy. 


394 


MODERN OPHTHALMOLOGY. 


INJURIES OF THE IRIS. 

On account of its protected position the iris rarely suffers from trauma 
without other tissues being involved. However, it may happen that the 
injury of the iris is of greater moment than is that of other parts. 

Iridodialysis, the most common of these conditions, is a tearing of the 
iris from the ciliary body. It often follows lacerated wounds and contusions, 
or may occur during operations on the iris, owing to unskillful manipula¬ 
tion or to rebelliousness of the patient. It is always accompanied by hem¬ 
orrhage into the anterior chamber (hyphemia). The blood may conceal 
the lesion for several days. The rupture may be very minute or large; or 
the whole iris may be torn from its attachments (traumatic irideremia), and 
be extruded from the eye or drop to the bottom of the anterior chamber, 
where it remains as a shriveled, grayish mass. If the rupture is small, 
vision is only slightly or not at all affected; if large, the patient will com¬ 
plain of monocular diplopia and dazzling. This is particularly true if the 
rupture is not covered by the upper lid. Idiopathic iridodialysis may result 



Fig. *270. —Iridodialysis. (De Beck.) 


from the growth of a tumor pushing the iris from its attachment. In trau¬ 
matic iridodialysis, under retinoscopic examination, a red reflex from the 
fundus shows through the rent. In iris-detachment from tumor it is absent. 

Treatment. —The eye should be protected from bright light and at- 
ropin should be frequently instilled. It has happened a few times that the 
iris has become reattached under this treatment. If the laceration is ex¬ 
tensive, the operation known as iridenkleisis, which is advised by Eugene 
Smith, of Detroit, can be performed. In this procedure the cornea is 
opened with a keratome and the torn iris is dragged into the wound and held 
in situ between the lips of the incision. Smith states that this operation 
will not cause sympathetic ophthalmitis. 

Anteversion of the Iris may follow iridodialvsis, the iris beimr twisted 
upon itself so that the pigment layer shows in front. The treatment is rest 
and atropin. 

laceration of the Sphincter of the Iris (Radiating Laceration) is a 

common result of contusion. The tear is usually small, and is discovered 
only by the most‘careful examination. These small tears are the cause of 
many cases of traumatic mydriasis. Large lacerations may extend to the 



DISEASES OF THE IRIS. 


395 


ciliary body. They are rarely met with. There is no particular treatment 
for this condition. Atropin makes the tear gape, and therefore should not 
be used. 

Inversion of the Iris is a rare condition due to trauma, and has not 
been satisfactorily explained as to its mechanics. The iris is turned back¬ 
ward and is doubled upon the ciliary body. The condition may be partial or 
complete. There is often an accompanying dislocation of the lens, and 
with it hemorrhage into the aqueous and vitreous chambers. Where the 
condition is total, absolutely no iris is to be seen. The treatment is entirely 
symptomatic. After the eye has become quiet attention should be directed 
to the refraction. 

Traumatic Irideremia.—Total loss of the iris, the other ocular struc¬ 
tures remaining intact, is an extremely rare condition, of which two exam¬ 
ples have been recorded by de Beck. Both cases sustained blows producing 
rupture of the cornea and extrusion of the iris without injury to the lens. 

Prolapse of the Iris.—After accidental injury, or following a cataract 
extraction, the iris may protrude through, or be caught in, the lips of a cor¬ 
neal wound. The diagnosis of iris-prolapse is easily made by inspection. 

Treatment. —If the prolapse follows an accident, the surgeon may 
either attempt to replace the prolapsed portion or excise it. The former 
method, which is condemned because of the danger of infecting the eye, 
is accomplished by gently pushing the iris back into place with a clean 
spatula, after the conjunctiva has been cocainized and flushed with a solu¬ 
tion of mercuric bichlorid or other antiseptic. After replacement a miotic 
is to be used three times a day for two or three da} r s. Prolapse of the iris 
occurring 'after a cataract extraction should be treated by excision (iridec¬ 
tomy) when the condition is observed early. If it is noticed after firm 
adhesions have formed, it should not be interfered with. 

Foreign Bodies occasionally rest in contact with the iris after perfo¬ 
rating the cornea. They may move with the movements of the eye or may 
remain imbedded in the stroma of the iris. They are necessarily of diversi¬ 
fied character, including fragments of iron, steel, guncaps, pieces of glass, 
grains of powder, etc. A rare condition is the transference of a cilium into 
the iris. A piece of steel or stone may rest in contact with the iris for a 
long period before causing inflammatory symptoms, but pieces of copper, 
even if aseptic, cause inflammation by chemic action. The detection of 
foreign bodies in contact with the iris is not difficult, provided the anterior 
chamber is not filled with blood or exudate. 

Treatment. —Foreign bodies which are freely movable are to be ex¬ 
tracted through a broad corneal section. Often the substance will be carried 
out by a gush of aqueous humor; if not, it can be drawn out by a magnet 
or seized with forceps. If the body is lodged in the iris, it can be removed 
by an iridectomy. Particles of powder, when driven into the iris, should 
be permitted to remain and the eye should be treated with atropin. Sidero- 
sis may follow the prolonged lodgment of pieces of iron or steel in the iris. 


396 


MODERN OPHTHALMOLOGY. 


MOTOR DISTURBANCES OF THE IRIS. 

The movements of the iris are indicated by change in the size of the 
pupil. Permanent dilation (mydriasis) and contraction (miosis) have been 
mentioned in Chapter IV. Hip pus , a clonic spasm of the sphincter pupilloe, 
characterized by constant changes in the size of the pupil, is found in some 
cases of hysteria, epilepsy, neurasthenia, cerebro-spinal sclerosis, dissemi¬ 
nated sclerosis, and in the early stage of acute meningitis. It may be present 
in normal individuals. 

Iridodonesis, tremulousness of the iris on movement of the globe, shows 
a lack of support, and, while not a functional motor disturbance of the 
iris, will be mentioned in this place. It is often seen after simple extraction 
of cataract. It exists in cases where the lens is present, but is shrunken or 
luxated; in cases of fluid vitreous; in persons with a high amount of myopia; 
in some nystagmatic eyes; and sometimes follows slight blows upon the eye. 
In the last-named cases, if the lens is not partially dislocated, there is prob¬ 
ably a rupture of some of the fibres of the zonula, establishing a communica¬ 
tion between the posterior and vitreous chambers. There is no treatment 
for this condition. 

CHANGES IN THE ANTERIOR CHAMBER. 

Depth.—The anterior chamber is deepened in the myopic and shallowed 
in the hypermetropic eye. Its depth in the normal eye varies, becoming 
less in accommodation owing to the forward movement of the anterior sur¬ 
face of the lens. It is lessened in infancy and in old age. Pathologically 
the chamber is shallowed in traumatic cataract as well as in a stage of ordi¬ 
nary senile cataract. In glaucoma, particularly in the acute inflammatory 
type of the disease, it is of less than normal depth. Intra-ocular tumors 
cause a shallowing. In some old cases of inflammation of the uveal tract, 
with detachment of the retina, there is a lessened secretion of aqueous humor 
and a shallowing of the chamber. In iritis with the formation of circular 
cynechise the chamber becomes shallow. 

Contents.—In iritis, iridocyclitis, and keratitis punctata the aqueous 
humor becomes turbid. In glaucoma it is turbid and contains a greater per¬ 
centage of solids than under normal conditions. Hypopyon, a collection of 
leucocytes and fibrin, is often seen in ulcers of the cornea and in violent 
attacks of iritis and iridocyclitis. 

Hyphemia, a collection of blood in the anterior chamber, is not infre¬ 
quently seen after injuries, both accidental and operative. It occurs idio- 
pathically in severe cases of iridocyclitis, in hemorrhagic glaucoma, in 
hemophilia, splenic leucocythemia, and in infra-ocular neoplasms. Disloca¬ 
tion of the lens into the anterior chamber may occur. Cilia are rarely 
carried into it through corneal wounds. The lodgment of such foreign 
bodies as pieces of iron, steel, copper, or stone often occurs. The parasites 
which have been found in this locality are cysticercus and filaria. 


DISEASES OF THE IRIS. 


397 


OPERATIONS ON THE IRIS. 

Of the numerous operations which have been devised and performed 
upon the iris, few are at present considered of value. They are iridectomy, 
iridotomy, and iridocystectomy. Corelysis, or the tearing of posterior 
synechige, and iridodesis—the tying of a piece of iris outside a corneal 



Eig. 271 .—First step in the operation of iridectomy. (Author.) 

wound—have justly been abandoned by reason of their producing sympa¬ 
thetic ophthalmitis. 

Iridectomy.—This is an excision of a piece of the iris. It may be 
done for an optical or for a therapeutic purpose. In the former, a com- 



Fig. 272.—Second step in the operation of iridectomy. (Author.) 

paratively small piece of the iris is generally excised, while a therapeutic 
iridectomy requires the removal of about two-fifths of the membrane. 

Optical Iridectomy. —This operation is indicated in the following 
conditions: (1) in obstruction or occlusion of the pupil, (2) in central 
corneal and lenticular opacities, and (3) in high degrees of keratoconus. 










398 


MODERN OPHTHALMOLOGY. 


Therapeutic Iridectomy is indicated: (1) in glaucoma; (2) as 
preliminary to cataract extraction; (3) in prolapse of the iris; (4) to _ 
remove tumors, parasites, or foreign bodies from the ins; (o) m chronic 
iritis; (6) to hasten maturation of cataract; (7) in corneal fistula; (8) 
in adherent leucoma and partial staphyloma, and (9) in the treatment of 
certain corneal ulcers which threaten perforation. 

The required instruments are speculum, fixation forceps, angular kera- 
tome, iris-forceps, scissors, and spatula. If tire operation is to be done upon 
an aphakic eye, a blunt iris-hook will be needed. \\ hile an optical iridec¬ 
tomy may often be done under local anesthesia, a therapeutic iridectomy 
usually requires general anesthesia. In children, nervous individuals, and 
insane patients chloroform or ether should be used. If a miotic has been 
used in the treatment of the case, it should be withdrawn several hours 
before iridectomy is attempted. The author has seen iridodialysis from 
an attempt to make an iridectomy in a case in which the miotic was not 



Fig. 273.—Third step in the operation of iridectomy. (Author.) 

discontinued. The steps in an iridectomy are three: (1) opening of the 
anterior chamber; (2) the seizure, withdrawal, and excision of the iris; 
and (3) the toilet of the wound. 

Execution of Iridectomy. —The field of operation should be cleansed. 
The patient reclining on an operating-table with the speculum in situ , the 
surgeon seizes the globe with the fixation forceps, placed usually below, while 
the iridectomy is to be made above. If, however, the case is one of threat¬ 
ened corneal perforation from an ulcer or a recent wound, it will be inad¬ 
visable to subject the globe to such pressure as will obtain if the instruments 
are placed as described above. In such an event it will be wdse for the sur¬ 
geon to seize the ocular conjunctiva eight or ten millimetres behind the 
corneoscleral junction, while the keratome is passed in front (Fig. 274). 

1. The Incision .—The keratome is to be passed through the cornea 
with a curved movement. At first the keratome is placed against the cornea 
at an angle of about 60 degrees; as soon as the point of the instrument is 
seen in the anterior chamber its direction is changed so that the point is 


DISEASES OF THE IRIS. 


399 


directed forward, thus avoiding injury to the iris, capsule, and lens. The 
keratome is gently pushed forward until an opening of sufficient size has 
been made. The instrument is then to be -withdrawn slowly, to avoid the 
sudden escape of aqueous humor and rapid reduction of intra-ocular ten¬ 
sion. “Perhaps the best idea of the action of the knife (keratome) is 
obtained by keeping in mind Arlt’s direction, that it is to be employed as 
a curved needle” (Norris and Oliver). 

2. Withdrawal and Cutting of the Iris. —Light, well-made, curved or 
angular iris-forceps, whose blades fit accurately, are introduced; the iris is 
seized near the pupillary margin and is gently drawn out of the wound. 
Undue traction on the forceps must be avoided. Cutting of the iris is then 
done with a pair of ordinary iris-scissors, or, as the author prefers, with the 
instrument of de Wecker. 

8. Replacement of the Iris-angles is done by gentle strokes with the 
spatula. 

In iridectomy for glaucoma the keratome is passed, not through the 
cornea, but through the sclera, one or two millimetres behind the cornea. 
The iris is withdrawn, cut at one end, then at the other, and finally at the 
base, care being taken to remove it far back to the periphery. The angles 
are then replaced as described above. 

An iridectomy which is made preliminary to a cataract extraction will 
require the excision of only a small amount of tissue. Many surgeons 
remove only a minute piece adjacent to the pupillary border (sphincterec- 
tomy). 

The after-treatment of an eye subjected to iridectomy is usually un¬ 
eventful. A piece of aseptic gauze is placed over both eyes, which are 
bandaged. The dressing is changed daily, and for a few days a drop or 
two of atropin solution will be instilled to prevent adhesions. If the iridec¬ 
tomy has been made for glaucoma, the atropin is used once only: i.e., at 
the first dressing. One such application will prevent adhesions, and will not 
cause increase of tension. 

Accidents during Iridectomy. — Among the accidents which may 
occur during an iridectomy are: (1) the passage of the keratome between 
the corneal layers; (2) spitting of the iris; (3) detachment (iridodialysis) ; 
(4) failure to excise the pupillary margin, thus leaving the sphincter in¬ 
tact; (5) injury to the anterior capsule of the lens; (6) rupture of the 
zonula; (7) dislocation of the lens, in consequence of sudden reduction 
of intra-ocular tension, into the groove between the root of the iris and the 
ciliary processes; (8) after making the incision the cornea collapses, indi¬ 
cating the presence of a firm cicatrix behind the iris and lens and making 
an iridectomy impossible; (9) the incision may be too small to permit the 
introduction of the iris-forceps. 

Iridectomy in Case of Obliteration of the Anterior Chamber. 
— Gayet’s Method is as follows: After fixing the eye with the double fixa¬ 
tion forceps a minute incision is made into the periphery of the anterior 


MODERN OPHTHALMOLOGY. 


400 

chamber with the ordinary scarificator, by sawing movements, enlarging the 
incision with blunt scissors. Dr. G. C. Harlan, of Philadelphia, has found 
this method useful in a case of chronic iritis with increased intra-ocular 
tension. The pupil was completely adherent at its margin, while the ms 
bombe lay directly against the cornea. It would have been impossible to 
make an incision with the keratome or von Graefe knife without involving 
the iris and possibly endangering the lens. He has found the narrow eber 
canaliculus knife useful in enlarging the incision, its probe-point passing 

readily between the iris and cornea. 

Deschamps’s Method—In aphakial eyes, with obliteration of the ante¬ 
rior chamber, the iris lies against the cornea, and the making of an iridcc- 
tomv by the ordinary procedure or by Gayet’s method will be practically 
impossible. In such cases Deschamps passes a cataract-knife at the corneal 
limbus through the iris and into the vitreous humor. The instrument is 
made to emerge at a point four or five millimetres away and the intervening 
tissues are cut. The iris is then seized with forceps from behind. It is 



Fig. 274.—Iridectomy in threatened corneal perforation. 

separated from the cornea, drawn out through the wound, and a piece is 
excised. 

Transfixion of the Iris.—In cases of iris bombe an operation which 
gives excellent results is the transfixion procedure. A very narrow von 
Graefe cataract-knife is passed through the cornea and bulging iris and 
withdrawn. The cut establishes a communication between the anterior and 
posterior chambers. At the same time retraction of the distended membrane 
practically forms a new pupil. 

Iridenkleisis.—This operation, which was devised by Eugene Smith, 
of Detroit, is employed for the relief of iridodi alysis. A keratome is passed 
somewhat obliquely through the cornea at a point in front of the detached 
portion of the iris. The torn edge of the iris is seized by means of iris-for¬ 
ceps and a small piece of the iris is drawn into the corneal wound, where it 
is held fixed by the compression of the lips of the wound. 

Iridotomy.—This operation, sometimes called iritomy, is an old pro¬ 
cedure which was advocated by Woolhouse in 1711, first performed by 
Cheselden in 1728, and revived in recent years by clc Weeker. It has 
undergone many vicissitudes. At the present day, however, it is performed 



DISEASES OF THE IRIS. 


401 


only on cases where iridectomy is impossible or dangerous. Although de 
Wecker sometimes performs this operation with the lens intact [(1) in 
zonular cataract, (2) central opacities of the cornea, (3) certain adherent 
leucomas, and (4) subluxation and luxation of the lens], among American 
and English surgeons its use is limited to cases in which, after removal of 
the lens, an adherent pupil exists. Formerly a broad needle or cataract- 
knife was passed into the anterior chamber and the iris (and tissues adherent 



Fig. 275.—Instruments used in operations on the iris. (Author.) 

1, Angular keratome. 2, Fixation forceps. 3, Angular iris-forceps. 4, Pince-ciseaux of de Weckcr. 

5, Spatula. 6, Blunt hook. The speculum has been omitted. 

to its posterior surface) was incised, the direction of the incision being 
across the iris-fibres. Contraction of the lips of the wound served to keep 
the artificial pupil open. The results were often unsatisfactory, leading 
surgeons to adopt the following operation:— 

Iridocapsulotomy.—This operation is indicated in certain forms of 
secondary cataract. Its object is the creation of an artificial pupil without 
excision of the iris. The necessary instruments are speculum, fixation 
forceps, keratome, one narrow' von Graefe knife, and the pince-ciseaux of 

26 




















402 


MODERN OPHTHALMOLOGY. 


de Wecker, of which one blade is sharp and the other blunt. The speculum 
being in position and the eyeball fixed, the surgeon passes the keratome 
through the cornea at a point one millimetre from the corneal limbus. 
The exact location of the corneal incision will depend upon the direction 
in which the thickened iris and lens-capsule are drawn. If the condition 
demanding this operation has followed a cataract operation, in which the 
upper corneal section was made, the keratotomy for the operation of irido- 
capsulotomy will be placed at the temporal end of the horizontal diameter of 
the cornea. The keratome is quickly withdrawn and the pince-ciseaux , with 



Fig. 276.—lridocapsulotomy. (De Wecker.) 


blades closed, is passed into the anterior chamber. The sharp blade is made 
to pierce the iris and lens-capsule, at a point two or three millimetres within 
the limbus. The instrument having been passed toward the nasal side, the 
blades are quickly closed, thus cutting the obstructing tissues (Fig. 276), 
which, if elastic, will retract and thus leave the desired pupillary opening. 

There are several modifications of this operation. If the pupil is drawn 
far upward, or is concealed by the corneal cicatrix, the operation represented 
by Fig. 277 will be valuable. A keratome is passed through the cornea and 
also through the iris, making an iridal incision (a-b) three or four milli- 



Fig. 277.—lridocapsulotomy. (De Wecker.; 


metres in length. At each extremity of this incision a cut (a-c; b-d) is 
made with the pince-ciseaux. If the tissues are elastic, a large pupillary 
opening will result. If the tissues do not retract, the procedure must be 
changed into an iridocystectomy. 

Iridocystectomy (Irido-ectomy). — 1 This is an excision of a part of the 
iris and thickened posterior capsule, and is indicated when, after a cataract 
operation or a traumatism, the pupil is closed by iridocyclitis or iridocap- 
sulitis. The required instruments are a speculum, fixation forceps, Beer’s 
cataract-knife or a keratome with a long narrow blade, Mathieu’s capsule 
forceps, and ordinary iris-scissors or de Wecker’s pince-ciseaux. 














DISEASES OF THE IRIS. 


403 


De Weckep/s Method. —A keratome is passed through the cornea and 
iris. From each extremity of the iridal incision a cut is made with the 
pince-ciseaux, thus excising a triangular segment of the obstructing mem¬ 
branes. The incision of the cornea and iris may be made with the narrow 
cataract-knife of von Graefe. This is followed by an excision of a triangular 
segment of the iris and capsule. 

Knapp's Method. —With the Beer knife the surgeon cuts through the 
lower part of the cofnea (if the cataract extraction was made above) and 
pierces the iris and adherent capsule, making a wound three and one-half 
to four millimetres long. A blunt hook is used to draw the lower lip of 
the iris outside the wound. In some cases the hook fails and the capsule 
forceps of Mathieu will be necessary. A piece of the iris and adherent 
capsule is then cut off, the eye is bandaged, and atropin is used for a few 
days. Healing is usually uneventful. The visual results of this operation 
are generally excellent. 


CHAPTER XI. 


DISEASES OF THE CILIARY BODY. 

The ciliary body, placed between the iris in front and the chorioid 
behind, participates in the diseases of these structures. This portion of 
the uveal tract is subject to congenital defects, to neoplasms, to inflamma¬ 
tions, and to injuries. 

Paralysis and spasm of the ciliary muscle are discussed elsewhere 
(Chapter XX). 


Fig. 278—Coloboma of the iris and ciliary body. (Bock.) 

Coloboma of the Ciliary Body is a rare anomaly which occurs either 
in connection with coloboma of the iris and chorioid or alone. Heretofore 
coloboma of the ciliary body has been seen only in a downward direction; 
nevertheless an anatomic study of those rare cases of iridic and chorioidal 
colobomata occurring together, in which the fissure is atypically directed, 
would probably show a similar condition of the ciliary body. Anomalies of 
this body present many forms: the coloboma may be covered by a yellow 
mass consisting of an enormous hyperplasia of the non-pigmented cells of 
the pars ciliaris, which may project into the vitreous humor; the ciliary 
muscle may be unchanged, while the ciliary processes show a pronounced 
cleft; or the ciliary body may be entirely wanting in the region of an iris 
coloboma. It is evident that the condition can be recognized only when 
an accompanying coloboma of the iris extends to the periphery. There is 
no treatment for these conditions. 

Tumors of the Ciliary Body.—Heoplasms originating in, and parasites 
transported to, the iris are certain in time to involve the ciliary body, which, 
however, may be the primary seat of a new growth or may be involved by 
(404) 



DISEASES OF THE CILIARY BODY. 


405 


metastasis. With the exception of tubercle and gumma, primary tumors of 
this part of the eye are very rare. Such a growth will cause iridodialysis, 
increased intra-ocular tension, repeated hemorrhages into the anterior cham¬ 
ber, and loss of the eye. By focal illumination the tumor can sometimes be 
seen as a dark mass lying behind the iris. The diagnosis will be difficult if 
the eye is painful and hard, without the tumor presenting. The presence 
of nodules or bulging at the ciliary region will show that the neoplasm is 
about to break out. The following growths have been observed: sarcomata 
of various kinds, myomata and fibromyomata, carcinomata, and angio¬ 
mata. The prognosis is serious, and the proper treatment is enucleation of 
the eye or exenteration of the orbit. Calcification and ossification are rarely 
found in this region. Parasites have been found in the ciliary body. In a 
few cases cysts have been found. 



Fig. 279.-—Leucosarcoma of the ciliary body and melanosareoma of the iris. 

(KERSCHB AUMER.) 

The lens is displaced and behind it an exudative membrane is seen. The optic nerve shows 

glaucomatous excavation. 

Gumma of the Ciliary Body is a rare condition, appearing in front one 
to three and one-half years after the initial lesion of syphilis. The gum¬ 
matous tumor is preceded by an attack of iritis. The vision is rapidly 
reduced, the eye showing great conjunctival and ciliary injection. The 
cornea becomes hazy, the anterior chamber deep, and hypopyon is present. 
A yellowish-red tumor is seen projecting from the angle of the anterior 
chamber, and at a spot corresponding to its site there is a bulging of the 
ciliary region. This is of a purple color. Tension becomes increased; there 
is great pain and considerable constitutional disturbance, as shown by the 
presence of anorexia, furred tongue, insomnia, and elevation of temperature. 
Other nodules appear, and these develop into ciliary staphylomata, present¬ 
ing a bluish-black color, owing to the pigment showing through the thin 
sclera. Under proper treatment, which has been instituted and continued for 
several weeks, the eye becomes clear, the hypopyon disappears, and the ten¬ 
sion gradually diminishes. Vision improves, but generally is not restored. 
The staphyloma may diminish in size, but some bulging always remains. 


MODERN OPHTHALMOLOGY. 


406 

If the treatment is not efficacious, the eye becomes perforated, or atrophy 

of the globe may occur without perforation. 

Diagnosis.— This must rest upon the history and clinical signs as 

given above. 

Prognosis should always be guarded in these cases. If the patient 
retains the globe intact and possesses vision equal to the counting of lingers 
at a few feet, he should be congratulated. Stieren, however, has recorded 
a case of gumma of the ciliary body, with vision reduced to perception of 
light, which recovered vision ( 6 / s ) under enormous doses (100 to 200 
grains, three times a day) of potassium iodid. 



Fig- 280.—Gumma of the ciliary body. (Norris and Oliver.) 

Treatment. —Antisyphilitic remedies should be pushed vigorously. 
Locally atropin or scopolamin drops must be used, and the usual remedies 
are to be prescribed for the relief of pain. 

INFLAMMATION OF THE CILIARY BODY. 

Inflammation of the ciliary body, known as cyclitis, may be idiopathic 
or traumatic; acute or chronic; simple or complicated. As regards the 
pathologic process, it is divisible into serous, plastic, and purulent forms. 

Serous Cyclitis (Descemetitis; Aquocapsulitis; Keratitis Punctata; 
Serous Iridocyclitis) is frequently described under the name of serous iritis, 
but properly comes under the head of this chapter, since Treacher Collins 


DISEASES OF THE CILIARY BODY. 


407 


has found that it depends on pathologic changes in the glands of the ciliary 
body. The disease presents the following 

Symptoms. —The corneoscleral region shows a delicate rose-colored 
injection. The anterior chamber is of normal or increased depth. The 
pupil is of normal size or slightly dilated. The tension is slightly increased 
at first, but diminishes later. The tendency to the formation of posterior 
synechias is not so marked as in iritis. The iris reacts slowly to light. 
Pain is rarely a prominent symptom. Exudation into the anterior chamber 
is moderate in amount, causing the aqueous and cornea to become cloudy. 
A deposit of opaque dots, often arranged in triangular form with the base 
downward, appears on the posterior elastic lamina of the cornea. The 
visual field may be contracted. A central scotoma may be present. 

Serous cyclitis may exist alone, but generally it is found associated 
with chorioiditis, interstitial keratitis, or scleritis. 

Etiology. —The disease occurs chiefly in ill-nourished, anemic young 
persons, particularly in women suffering from uterine diseases. According 
to Horner, it is more frequent in women than in men in the proportion of 
10 to 3. Some cases are undoubtedly due to syphilis, either early or as a 
late manifestation, while others have been attributed to rheumatism, gout, 
eyestrain, or to trauma. A serious form of this affection is caused by 
sympathetic ophthalmitis. 

Pathology.— The investigations of Xicati, in 1891, showed in rabbits 
the existence of glands in the ciliary body for the secretion of aqueous 
humor. Treacher Collins, working about the same time, demonstrated 
by bleached sections the existence of similar glands in the human eye. 
Serous cyclitis is a catarrhal inflammation of the ciliary glands. Hyperemia 
is followed by increased secretion and deepening of the anterior chamber. 
The aqueous humor becomes more albuminous than normally. A few 
leucocytes, together with pigmented epithelial cells thrown off from the 
surfaces of the glands, and shreds of fibrin are present. These solid 
elements drop to the bottom of the anterior chamber and form the dots of 
so-called “keratitis punctata.” Leucocytes collect in the ligamentum pec- 
tinatum and hinder the egress of aqueous, thus causing increased tension. 
The turbidity of the aqueous humor causes the iris to lose its lustrous ap¬ 
pearance. Severe cases may end in involvement of the vitreous humor with 
shrinking of the globe and development of cataract. 

Prognosis. —Except as a manifestation of sympathetic ophthalmitis, 
serous cyclitis offers a favorable prognosis. Adhesions do not often form 
between the iris and lens-capsule, but sometimes permanent opacities are 
left in the cornea and vitreous humor. The disease runs a slow course. 
When associated with marked fundus changes it may lead to blindness. 

Treatment. —The internal use of mercury and potassium iodid is of 
value in these cases. Mercury used by inunction or hypodermically is an 
efficient remedy. If the patient is anemic, tonics are to be employed. In 
the cases due to gout and rheumatism, Turkish baths, diuretics, tonics, 


408 


MODERN OPHTHALMOLOGY. 


and exercise, together with appropriate diet, are to be employed. As regards 
local treatment, the use of weak solutions of atropin is of value. If the 
tension is increased, paracentesis of the anterior chamber should be done, 
followed by the use of pilocarpin, arecolin, or weak eserin solutions. The 
presence of vitreous opacities will call for the vigorous use of mercury and 
diaphoretics internally. Use of the eyes for near work should be pro¬ 
hibited. As a rule, the patient should not be kept in a dark-room. The 
management of those cases which are due to sympathetic ophthalmitis will 
be described elsewhere (Chapter XVIII). 

Plastic Cyclitis (Iridocyclitis Plastica) is the severest form of inflam¬ 
mation of the ciliary body. The symptoms are great pain, chemosis of the 



Fig. 281. —Anterior part of eyeball with iridocyclitis. (After Pollock.) 


Section of an eye which received an extensive wound followed by hemorrhage, prolapse 
of the iris, and loss of vitreous. Iridocyclitis ensued, and the eye was enucleated thirty-nine 
days after the injury. 

1, Conjunctiva. 2, Sclerotic. 3, Cornea. 4, Cicatrix of the wound passing obliquely 
through the cornea, with pigment deposit. 5, Stretched and atrophied iris adherent to the capsule 
of the lens. 6, Pupillary margin of the iris which is adherent to the cornea (anterior synechia). 

7, 7, Capsule of the lens. 8j Folded remains of part of the lens-capsule, imbedded in cicatricial 
tissue. 9, 9, Newly formed connective-tissue membrane passing across the globe behind the lens. 

10, 10, Detached and folded retina. 11, Ciliary body, dragged inward. 12, Tigment layer of 
pars non-plicata of ciliary body. IS, Pigmented cells in the chorioid. 14, Chorioid. 15, Blood- 
clot splitting the chorioid into two layers. 16, Newly formed inflammatory membrane, showing 
fibres, round cells, pigment-vessels, and traces of the incarcerated and destroyed iris. 

conjunctiva, and swelling of the lids. The eye is exceedingly tender to pres¬ 
sure over the ciliary region. There is great pericorneal injection, and exuda¬ 
tion takes place into the pupil, behind the iris, and into the vitreous humor. 
Often the pupil is dilated by the contraction of plastic exudate deposited in 
the ciliary body. If the disease follows an attack of iritis, all the symptoms 
are accentuated. Early in cyclitis the tension is increased. The disease is 
accompanied at times by intense pain, vomiting, and fever. Photophobia 
and lacrimation are often present. 

Etiology. —The most frequent cause of plastic cyclitis is traumatism 
(perforating wounds, cataract operations, etc.). It occurs idiopathically as 
a result of a similar process in the other eye (sympathetic ophthalmitis). 




DISEASES OF THE CILIARY BODY. 


409 


Stephenson—in view of the fact that numerous inflammatory diseases of the 
iris and chorioid result from depraved blood-conditions, which, in turn, are 
attributed to microbic causes—regards the excretion of microbes or their 
products by the ciliary body as the cause of all cases of endogenous irido¬ 
cyclitis. 

Pathology. —The first step in the morbid process is hyperemia with 
transudation of leucocytes. The characteristic feature of the disease is the 
fibrinous exudate, which appears on the inner surface of the ciliary body, 
on the zonula of Zinn, in the posterior chamber, and in the vitreous humor. 
The inflammatory process may end in resolution, the exudate being ab¬ 
sorbed, or it may become organized. Vessels from the ciliary body or from 
the peripheral parts of the retina grow into it. The iris becomes adherent to 
the lens, thus obliterating the posterior chamber; and contraction of the 
newly formed membranes, with detachment of the retina and ciliary body, 
takes place. The nutrition of the lens being interfered with, cataract re¬ 
sults. The eye finally becomes shrunken and soft: a condition known as 
atrophy of the eyeball. 

Prognosis.— This form of cyclitis is rarely improved by treatment. 

Treatment. —The treatment is that of a severe case of iritis with the 
addition of large doses of mercury and potassium iodid, together with dia¬ 
phoretics. If the eye becomes blind and shrunken and is painful to the 
touch, it should be enucleated. 

Purulent Cyclitis.—This disease is caused by infected wounds and 
acute infectious diseases. It runs a sharp course. Hyperemia, round-cell 
infiltration, and the presence of pus in the anterior chamber are prominent 
pathologic features. The symptoms are all accentuated. If the disease is 
due to a wound, the eye is lost by panophthalmitis. Purulent cyclitis some¬ 
times appears idiopathically in the course of influenza, small-pox, and 
scarlatina. 

Prognosis. —This is unfavorable. 

Treatment. —This will consist of hypodermic injections of morphin 
to relieve pain and the local use of atropin, hot compresses, and bichlorid 
solution. Inunctions of mercury and subconjunctival injections of the same 
drug may be employed. 'Most cases of purulent cyclitis end in phthisis bulbi 
and require enucleation. 

Injuries of the Ciliary Body are among the most dangerous traumatisms 
of the eye, and are particularly prone to cause sympathetic ophthalmitis. 
The iris and lens are almost invariably injured at the same time. If the 
instrument producing the trauma remains within the globe, the case becomes 
much complicated, and comes under the head of retained foreign body. If 
the instrument has been withdrawn, and has not carried infection into the 
eye, the case may do well, or the eye may be lost by a slow iridocyclitis. 
Careful inspection is necessary in all eye injuries. In the management of 
these cases cleanliness should be absolutely observed by the surgeon. If 
the wound is of considerable extent and involves the sclera, it can be 


410 


MODERN OPHTHALMOLOGY. 


treated by snipping off any protruding bead of vitreous humor and by 
suturing the sclera. Whenever possible to do so, the scleral wound should 
be covered by a sliding conjunctival flap. It is only in those extensive 
lacerations where there is no hope of vision that an immediate enucleation 
should be made. Under any other circumstances the patient is to be given 
the benefit of skilled advice. In these cases the general practitioner will not 
be doing his duty unless he observes absolute cleanliness and refers the case 
to a specialist. 


CHAPTER XII. 


DISEASES OF THE CHORIOID. 

The chorioid coat is part of the uveal tract and is characterized by 
its vascular and pigmentary supply. It is subject to congenital anomalies, 
tumors, inflammations, and injuries. 

CONGENITAL ANOMALIES. 

Coloboma of the Chorioid and Retina may be considered together, 
since for practical purposes there can be no coloboma of one tunic without 


Fig. 282.—Coloboma of the chorioid. (Benson.) 

the other being absent, although microscopic examination sometimes demon¬ 
strates the presence of the retina in cases of chorioidal colobomata. Eyes 
in which portions of the chorioid and retina are wanting are often hyper¬ 
metropic, nystagmatic, strabismic, and amblyopic. The defect is usually 
situated in the lower part of the fundus. Generally the iris presents a 
coloboma also, but cases are on record in which coloboma of the chorioid 
was the only malformation. With the ophthalmoscope the coloboma is 
seen as a whitish, pearly patch, of round or ovoid shape, often with a pig¬ 
mented border, presenting a few retinal vessels in its area. The sclera may 
bulge at the site of the coloboma ami resemble a cyst. Microphthalmos and 
imperfect development of the nervous system and of the skull are not 
infrequent accompaniments of chorioidal colobomata. The surface of the 

(411) 




412 


MODERN OPHTHALMOLOGY. 


coloboma can be seen to be deeper than that of the surrounding letina. 
Similar white depressions are sometimes seen in the macular region and 
are called macular colobomata. Of these, about 40 cases are recorded, of 
which 5 were bilateral. A coloboma of the macula usually presents a white 
or yellowish area of a round or oval shape, whose border often shows pig¬ 
mentation. It is traversed by retinal vessels. In rare instances chorioidal 
vessels are present resembling vascular convolutions, and this condition 
has led Lindsay Johnson to regard macular colobomata as the atrophied 
remains of nevoid growths in the chorioid. Most cases of macular coloboma 
show myopia. Visual acuity may range from high amblyopia to normal 
vision. The field of vision shows a defect, scotomata of various forms being 
found in different cases. In a nystagmatic eye, to differentiate between 
chorioidal atrophy and coloboma may be difficult. Aside from the correc¬ 
tion of the refraction, there is no treatment for coloboma. 



Fig. 283.—Coloboma of the macula, with islets of pigment and 
an atrophic crescent of the optic disc. (Silex.) 

Albinism (Leucosis).—Congenital absence or insufficiency of pigment 
in the uveal tract causes the iris to look pinkish or yellowish, from rejec¬ 
tion of light from the iridal and chorioidal vessels. The chorioidal vessels 
are visible ophthalmoscopically. Nystagmus, strabismus, errors of refrac¬ 
tion, and reduction in visual acuity are frequent accompaniments of albin¬ 
ism. Treatment is limited to the correction of errors of refraction and to 
the shading of the eyes with dark glasses. 


TUBERCULOSIS OF THE CHORIOID. 

Tubercles of the Chorioid (Fig. 2, Plate XIII) may be in the form of 
miliary tubercles accompanying general acute tuberculosis, or as large masses 
in chronic tuberculosis. In miliary tubercle a few tubercles (one to ten) are 
found in the macular region or are scattered over the fundus. Each tubercle 
usually measures from one-third to two-thirds the diameter of the optic disc, 




DISEASES OF THE CHORIOlD. 


413' 


but may be larger. It appears as an oval, round, or reniform spot of a pale- 
rose, grayish-yellow, fawn, or paper-white color. Its edges appear “moth- 
eaten,” and are marked by a narrow zone of retinal pigment. Its surface 
may present specks of pigment, dots, or pinkish stripes. They resemble the 
spots seen in disseminated chorioiditis. When multiple, the common num¬ 
ber is two or three. The tubercles in this form of the disease appear a few 
days or weeks before death; hence, they cannot be mistaken for the elevations 
of disseminated chorioiditis. They begin in the deeper layers of the chorioid, 
growing from the adventitia of the vessels. They do not affect the vision. 
In many cases they can be demonstrated by microscopic section in eyes 
which present no changes to the ophthalmoscope. In probably 80 per cent, 
of cases of miliary tuberculosis their presence can be demonstrated post¬ 
mortem. According to Carpenter and Stephenson, they are found oph- 
thalmoscopically in 50 per cent, of cases of acute miliary tuberculosis and 
tuberculous meningitis, and in 10 per cent, of cases of chronic (surgical) 
tuberculosis. The presence of tubercle bacilli cannot always be demon¬ 
strated in the cases. The larger tubercles show giant cells with a re¬ 
ticulum of fibres, epithelioid cells, small-cell infiltration, and caseation. 
The smaller growths are collections of lymphoid cells situated between the 
vessels. Since this disease appears very late in an incurable malady, treat¬ 
ment is valueless. The presence of tubercle in the chorioid may assist the 
physician in making a diagnosis between acute miliary tuberculosis, typhoid 
fever, and meningitis. While of serious import, in rare instances they may 
disappear or become quiescent. In chronic tuberculosis the chorioidal lesion 
may be single, multiple, disseminated, or diffused. The treatment is limited 
to hygienic and constitutional measures. 

A Large Tubercular Mass often presents the clinical picture of a sar¬ 
coma of the chorioid. It is probably always secondary to tuberculosis located 
elsewhere, although the latter may defy localization. The disease is usually 
unilateral. In rare cases the patient may early show a destructive inflam¬ 
mation of the globe with perforation, or the disease may cause no symptoms 
and may be accidentally found by ophthalmoscopic examination. In a few 
cases glaucoma appears. Since the disease occurs chiefly in children and 
young subjects, it may be mistaken for neuroepithelioma of the retina. 
There is much variety in the ophthalmoscopic appearances of this disease. 
The tubercular mass usually appears as a solitary white or grayish elevation, 
springing from the central part of the fundus. It is to be distinguished 
from leucosarcoma of the chorioid, neuroepithelioma of the retina, and 
subretinal cysticercus. The absence of vessels serves to exclude the first 
and second conditions, while its immobility and solidity will distinguish it 
from cysticercus. 

Since the tubercular tumor is secondary to tuberculosis located else¬ 
where, the removal of the eye is not demanded at an early stage, provided 
the diagnosis is clear. If it is in doubt, the eye should be removed and 
subjected to microscopic examination. Cases of tubercular tumor which 


414 MODERN OPHTHALMOLOGY. 

4 

are progressive and tend to perforate should be treated by enucleation. The 
general treatment of the patient is of great importance in these cases. After 
a successful operation the patient may die from tuberculosis of the me¬ 
ninges, lungs, or abdominal viscera. 


TUMORS OF THE CHORIOID. 

Carcinoma of the Chorioid is of rare occurrence, Oatman having col¬ 
lected only thirty cases. The disease is always metastatic. The rarity of 
metastatic growths in the eye is accounted for b} T anatomic conditions: the 
small size of the ophthalmic artery and the fact that it is given off from the 
internal carotid at an angle of ninety degrees, V hile metastasis should 
be more common in the left eye than in the right, owing to the difference 
in the carotids, statistics do not show this to be true. The left carotid should 
receive emboli more easily than the right, inasmuch as it rises from the aorta 
directly. Metastatic growths occur most often at the posterior pole of 
the eye, owing to the great calibre of the short ciliary arteries. Of 28 



Fig. 284.—Metastatic carcinoma of the chorioid. 

cases in which mention is made of its location, the primary growth was 
situated in the breast in 20 cases; in the lungs in 3, in the liver in 2, in 
the stomach and liver in 1, in the suprarenal capsule in 1, and in the thy¬ 
roid gland in 1. In one-third of the cases the disease was bilateral. The 
ages of the patients ranged from thirty to fifty-eight years. The disease 
is twice as frequent in females as in males. Vision is destroyed within a 
few weeks after the appearance of ocular symptoms. The average dura¬ 
tion of life is about six months. 

The disease appears ophthalmoscopically as a “flat, oval deposit or 
tumor, on the temporal side of the nerve, involving the macula with a cen¬ 
tral elevation of 3 D., its edges gradually fading off into the surround¬ 
ing fundus. Its color is a dirty-yellow, with scattered pigment spots” 
(Mitvalski). No vessels are apparent in the growth. The retina becomes 
detached at an early period. The tension of the affected eye may be normal, 
increased, or reduced. Enucleation may be necessary to relieve pain. 

Other Tumors of the Chorioid.—Aside from the occurrence of car¬ 
cinoma and the solitary form of tubercle, which have been considered, the 
chorioid is the seat of sarcomata, myomata, cysts, and nevi. Sarcomas 


DISEASES OF THE CHORIOID. 


i 


415 


occur either primarily or by metastasis. They belong to the middle period 
of life, being rarely seen before the thirty-fifth year. Some are white 
(leucosarcomata) while others are black (melanosarcomata). The latter 
derive their color either from the presence of melanin or from the pigment 
of the blood. Their tendency is to grow out of the globe in three direc¬ 
tions: (1) along the course of the venae vorticosae, (2) along the optic 
nerve to the brain, and (3) to the corneoscleral junction. They may perfo¬ 
rate the sclera in other places. Their microscopic appearance is variable, 
and more than one type of structure may be found in the same growth. 
The small round-cell and spindle-cell tumors are common. Angiosarcoma, 
telangiectatic sarcoma, adenoma, perithelioma, and enchondroma are very 
rare chorioidal growths. 

Sarcoma of the Chorioid.—This disease (Fig. 1, Plate XIII) is found in 
the proportion of about 1 to 3000 ophthalmic patients. In the vast majority 



Fig. 285.—Fungating sarcoma of the chorioid. ^Author.) 


of cases the growth is primary. However, the author has met with one case 
of chorioidal sarcoma sequent to a sarcoma of the leg. In another metastatic 
case, which was observed by Meigs and de Schweinitz, the primary growth 
was located in the mediastinum. Doubtless metastatic sarcoma of the chorioid 
occurs more frequently than is supposed, since in many cases of sarcomatosis 
the eyes are not examined. The primary intra-ocular growth is usually single 
and unilateral, and generally is in the form of a projecting knob, growing 
toward the centre of the eye, and presenting a neck and base. Sarcoma 
may appear as early as the fifteenth or as late as the eighty-fourth year, 
although it is most frequent between the age of forty and sixty. The 
disease is said to be more common in males than in females (Fuchs, A. 
Hill Griffith, Lawson) ; but Kerschbaumer states that sex is without in¬ 
fluence. After removal of the eye the disease often becomes metastatic, 
invading any organ or tissue, not excepting the bones. The brain is rarely 
involved by extension along the optic nerve. A rare complication is pig- 




416 


MODERN OPHTHALMOLOGY. 


mentation of the skin, either in the form of a diffuse dark color, suggestive 
of argyrosis, or in the form of small, discrete round spots, two to four 
millimetres in diameter, which may be too numerous to be counted. In 
some cases of melanosarcoma of the chorioid melanin is found in the urine. 

Symptoms.—T hese vary much in different stages of the disease:— 

1. In the first stage a detachment of the retina is seen at the site of 
the tumor. The mass appears of a purple-red or slate color according to 
its pigmentation; if deeply pigmented, it may appear black. Blood-vessels 
are seen coursing over it. There is no pain, and the tension is normal. 
The defect in the visual field may take an hemianopic shape or be quite 
irregular. Vision in the first stage may be only slightly or considerably 
reduced, according to the proximity of the growth to the macula. The 
duration of the first stage is from one to two years. 

o «/ . 

2. In the second stage there is increase of tension, while the external 
appearance of the eye resembles that found in inflammatory glaucoma: the 
anterior chamber is shallow, the pupil dilated, the cornea cloudy, and 
dilated episcleral vessels are visible. If the media are clear, a detached 
retina is seen. Later the lens becomes opaque and the clinical picture is 
that of absolute glaucoma. Pain now appears and makes the glaucomatous 
picture so striking that experienced diagnosticians have been deceived. 

3. In the third stage the tumor escapes from the globe, the symptoms 
varying according to the place of exit. If in front, dark nodules are seen 
about the corneoscleral region. The area of impending perforation bulges 
and presents a rich development of blood-vessels, together with a black 
or bluish discoloration (Fig. 4, Plate XII). If behind, the existence 
of perforation cannot be told until the growth produces exophthalmos. 
Pain is relieved by the perforation of the globe. The growth of the sar¬ 
coma then proceeds with startling rapidity. The tumor fills the orbit and 
may cause a projection as large as two fists. The exposed parts of the mass 
ulcerate and bleed; the deeper portions may grow into the brain. 

4. In the fourth stage, metastatic nodules form in the internal organs, 
the liver, stomach, and mesenteric glands being favorite sites. The patient 
dies by exhaustion. The first and second stages may occupy several years; 
the third and fourth stages are measured by months. 

Diagnosis. —In making a diagnosis of sarcoma of the chorioid the 
following conditions must be reckoned with:— 

1. Detachment of the retina and chorioid. 5. Glaucoma. 

2 . Neuroepithelioma of the retina. 6. Spontaneous rupture of the eyeball. 

3. Solitary tubercle of the chorioid. 7. Iridocyclitis. 

4. Intra-ocular cysticercus. 8. Syphilis with chorioidal exudation. 

1. (a) Retinal Detachment caused by sarcoma of the chorioid differs 
from the simple variety. In the latter the retina, early in the history 
of the case, is transparent, owing to the absence of the color given to it bv 
the chorioidal pigment. Spontaneous retinal detachment is preceded by 


PLATE XIII, 
Eisaasas nf tha Choriaid. 


Fig. 1,—Saraama af tha Charioid. 


Fig, 2.—Tubercles of th.a dLoriaid. 


a |«?i ' 


I TJX 3Tiv.FI 

j Kiy. 

TiDxioJC! oiit In saaspstd 

» d fuse da Jo color, suggestive 
• : 10 round spots, two 10 lour 

u?r* us to >0 counted. In 
. . . . jteiarmH's found in the urine. 

< c i i stages of the di~ wie‘ — 

i is 'isi.; site of 

>. r < or slate'etiloi .Mvording to 
. •;»!' *■ may appear black. Jt< • --Vessels 

< ... jt. Tii x f ;m. and the t -nsi >n ■ -mai. 

in J . vi ual field mv t.*k° in hemianopic sliupe o <nt> 

.,*>• .!■,*..< > the proximity of the growth to tne macula. Tint.: 

n, U uiupa62-.t. ; e^ 

is increase of te;vn u, w • • 

i •( of the eye resembles that found in inflauwna u v < iancoma: the 
;;; • Jr:r chamber is shallow, the pupil dilated, the cornea cloudy, and 
■ J •• - -K-ra' \. sseis are \isihly. If the media ate < ha. \ a detached 

h;;e aueoiua. Pair now appears and: makes ' m 1 • natous 
t» : I,mg experienced diagnosticians have d-'-mved. 

thin 1 , -stage the tumor escapes from the globe, •:'.proms 

rvim: i n ing If* tin place of * it. !f in front, dark uorj : - ar seen 

' 


nr>ite a 'eoiopment of 


-x osce's, ioget tier v 




hi auk 

Ipfw ; ’ . 4. "leu- \! i1.1 fjeiun 

i<« '<! a nth th growth produo •• m mail, v 


v. { . J.'-tf; cap aify. tuu.iov the orbit and 


sod parts of the mass 












it- mal organs, 


Til M co ~-.l f 

1. Detachnj* or ••{ . > 

2. Nourpeplthei w ; n o 

3. Solitary t uberele <>\ 

4 Intra orulftr «v-t. pi ■ 


.iDiclacxiD sdt to e.alaiBdxri'—-.S ,gn 


■ ;• patient 
w.-ral years: 

ohorie.id the 


of the eyeball 


. avion. 


7. (a) Tic: <f l D'fa ■■ .< 
fnau the simple variety. Id 1 
‘•f Uie case, ;> transparent, owir 
if - chori ddul pigment. boon 


oid differs 
•e b'.rtpry 
to it by 
dec! by 


PLATE 13 









DISEASES OF THE CHORIOID. 


417 


muscae volitantes. It appears suddenly, and is accompanied by vitreous 
opacities, reduced tension, and signs of chorioiditis, and often occurs in 
eyes which are highly myopic. The condition of the other eye as regards 
refraction, the state of the fundus, and the history of the case are of some 
value. Holden says that the simple form of retinal detachment extends to 
the ora serrata, while in tumor the detachment is longer delayed, particularly 
when the tumor is in the ciliary body or in the posterior pole of the eye. The 
detachment in the simple form tends to produce folds and show undulations 
on movement of the eye, while in tumor the folds are generally absent and 
the mass does not undulate. However, cases occur in which serum col¬ 
lects between a sarcoma and the retina, thus simulating simple detach¬ 
ment and making the diagnosis difficult or impossible. In some of these 
cases, where the retina is not thickened and the sarcoma is rich in vessels, 
the tumor may be recognized by the presence of vessels which are neither 
chorioidal nor retinal. As a rule, a large detachment of the retina, pressing 
against the lens, will be due to an underlying sarcoma. Tension is a valuable 
diagnostic point: in retinal detachment due to a serous collection it is 
generally decreased; in chorioidal sarcoma it is usually normal at first 
and becomes increased later. A dilation of the anterior ciliary veins, when 
localized to one part of the globe, indicates sarcoma, the growth interfering 
with the return of the hlood through one of the venae vorticosae. In melano- 
sarcoma the urine sometimes contains melanin, and turns black on the 
addition of perc-hlorid of iron. 

BellarminofPs device may assist in making a diagnosis. The eye being 
anesthetized, a piece of moistened plane glass is pressed against the cornea, 
thus causing it to become flat and eliminating its refraction. By using 
strong illumination the opaque sarcoma may sometimes be recognized be¬ 
neath the detached retina. Tubular devices for trans-scleral illumination 
may be of value. Light is concentrated on the sclera while the surgeon notes 
the fundus reflex. When the apparatus is placed opposite an intra-ocular 
tumor, the fundus reflex becomes dimmer. 

In case of doubt, the diagnosis resting between sarcoma and retinal 
detachment, Hirschberg proposed to puncture the eye. If a sarcoma is 
present, blood will be drawn; if the case is one of detachment, only serous 
fluid will be obtained. Hirschberg, however, has abandoned this procedure. 
It is uncertain, and, furthermore, it may furnish a path by which extra¬ 
ocular extension may occur. In any instance of doubtful diagnosis, the 
vision being markedly reduced or entirely lost, an enucleation will be justi¬ 
fied on the ground that it is better to remove a dozen useless eyes, which 
are blind from retinal detachment, than to leave a case of chorioidal sarcoma 
till the third stage is reached. 

(b) Detachment of the Chorioid presents even more problems in dif¬ 
ferential diagnosis. It forms a circumscribed projection, standing out 
prominently upon the fundus like a sarcoma. The foldings, present in 
simple retinal detachment, are absent in detachment of the chorioid. Usu- 

27 


418 


MODERN OPHTHALMOLOGY. 


ally in chorioidal detachment there is hemorrhage and chorioidal vessels 
can be recognized beneath the retinal vessels. Fortunately the condition 
is extremely rare. Transient detachment of the chorioid, following cataract 
extraction, has been observed bv Fuchs (see Chapter XIII). 

2. Neuroepithelioma of tue Retina .—Here the age of the patient is 
of importance. Xeuroepithelioma is found only in children. W liile sar¬ 
coma of the chorioid may occur in childhood, such cases are exceptional. If 
the media are clear, a diagnosis between neuroepithelioma and sarcoma is 
usually not difficult. The former presents a yellowish-white tumor (Fig. 7, 
Plate XII). A sarcoma, if pigmented, looks much different. In a later 
stage, when glaucomatous symptoms arise, diagnosis will be difficult. 

8. Solitary Tubercle of the Chorioid may be mistaken for leucosarcoma. 
Tubercle, however, does not show vessels, and occurs, for the most part, in 
young tubercular subjects. 

J t . Intra-ocular Cysticercus is of such rare occurrence in this country 
as to demand no consideration. In the early stages, before the advent of 
inflammatory symptoms, the picture of cysticercus is characteristic and 
can hardly be mistaken for sarcoma. 

5. Glaucoma. — The differential diagnosis between sarcoma of the 
chorioid and acute inflammatory glaucoma which has been untreated may 
be impossible. The author once made an iridectomy for the relief of pain 
for what was diagnosticated as glaucoma absolutum. Improvement was 
but temporary; the pain returned and in a few weeks an enucleation 
showed the case to be sarcoma of the chorioid. In such a case the media 
are opaque, the eye is hard, the episcleral vessels are dilated, and the pain is 
severe. It will rarely happen in glaucoma that one eye will be entirely 
blind and the other eye normal. 

6. Spontaneous Rupture of the Eyeball , of which the author has 
observed one case, and Gilfillan and Millikin have recorded others, presents 
a picture identical with that found in the third stage of sarcoma of the 
chorioid. The history of the case, and the excessive rarity of spontaneous 
rupture, will serve to clear the diagnosis. 

7. Iridocyclitis .—Here the chief difficulty arises because of clouding 
of the media, occlusion of the pupil, and opacification of the lens. It some¬ 
times occurs that, in the course of its growth, a chorioidal sarcoma will cause 
chorioiditis and iridocyclitis of such intensity as to lead to phthisis bulbi. 
In a case of idiopathic iridocyclitis both eyes are frequently affected. Ten¬ 
sion is usually reduced, while in sarcoma tension is usually increased after 
the period when the media are clouded. In traumatic iridocyclitis the his¬ 
tory of the case will clear the diagnosis. 

S. Syphilis .—Post has recorded a case of sarcoma, occurring in a 
myopic syphilitic subject. There were floating opacities in the vitreous 
humor and a projecting mass was seen between the macula and the optic- 
nerve head. No improvement followed antisvphilitic remedies. The eve 
was enucleated and was found to contain a leucosarcoma of the spindle-cell 


DISEASES OF THE C'HORIOID. 


419 


type. In this connection it may be stated that Silcock has reported a case 
of gumma of the chorioid. 

Pathology. —Sarcoma of the chorioid usually is a firm tumor, but 
is sometimes gelatinous and may undergo fatty, myxomatous, osseous, or 
cartilaginous degeneration. Histologically it consists either of round or 
spindle cells or a mixture of both. It is usually of the small-cell variety. 
It arises either from the outer or middle layers of the chorioid, and its 
tendency is to grow inward toward the vitreous. Earely the tumor is flat; 
its common form is spheroidal as long as its chorioidal covering is intact. 
Later it breaks through the lamina vitrea and assumes a spheric shape. 
In its growth it detaches the retina throughout a large area, but at the apex 
the tumor and retina are intimately attached. Following the detachment 
comes a stage of inflammation, in which either glaucoma or iridocyclitis is 
set up, the latter leading to atrophy of the eyeball. Occurring under these 
circumstances, atrophy of the globe is supposed to be due to iridochorioiditis 
caused by degeneration in the neoplasm and by microorganisms (Leber, 
Ivrahnstofer, Evetsky). Kipp has recorded a case of chorioidal sarcoma fol¬ 
lowed by atrophia bulbi. Twenty years later perforation of the globe and 
rapid growth of the neoplasm occurred. The stage of extension follows, the 
tumor spreading along the optic and ciliary nerves, or along the course of 
vessels entering the globe. Nodules form in the orbit and thus exophthal¬ 
mos is produced. Metastases form in distant organs by embolism, the blood- 
current detaching and carrying the cells to other parts. While local recur¬ 
rences are unusual after cases operated upon at an early stage, metastases 
sometimes occur long after the removal of the eye. Sarcomas of the 
chorioid belong principally to the pigmented tumors (melanosarcomata). 
The leucosarcomata are rare. 

Prognosis in chorioidal sarcoma is always grave. If the tumor-mass 
has reached the third stage, it is generally absolutely bad. An early diag¬ 
nosis and thorough operation made in the first or second stage will save 
about 40 per cent, of these cases. The danger of local return under such 
circumstances is small, but the liability to the development of metastases is 
great. These usually appear within six months after enucleation. If the 
patient remains well for four years after operation, the immunity is prob¬ 
able, but is not assured. In untreated cases the duration of life is said to be 
about five years. The prognosis is more favorable in spindle-cell sarcoma 
than in the round-cell variety. 

Treatment. —Only surgical procedures are of value in chorioidal sar¬ 
coma. If the tumor has not passed beyond the second stage, an enucleation, 
with complete resection of the orbital part of the optic nerve, its mem¬ 
branes, and the surrounding tissue at the apex of the orbit, will be suffi¬ 
cient. If there is doubt about the second stage being past, or if the tumor 
has undoubtedly extended beyond the globe, a complete removal of the orbital 
contents must be effected. This can be done rapidly and efficiently, a scal¬ 
pel, scissors, and forceps being the only instruments necessary. The 


420 


MODERN OPHTHALMOLOGY. 


author believes that, with the modern methods of operating, the use of 
caustics in the orbit should be eschewed. In operating on cases in the third 
stage the aim of the surgeon is more to relieve pain and destroy fetor than 
to save life. Here the hypodermic injection of the toxins of erysipelas and 
of bacillus prodigiosus or exposure to the x-ray may be tried. In the fourth 
stage treatment is useless except to relieve pain. 

Myoma of the Chorioid.—Although the interior of the eye is well sup¬ 
plied with material for the growth of muscular tumors, few cases of ocular 
myomata are on record. This form of tumor has been found several times 
in the chorioid. In the case reported by Guiata, of Siena, the diagnosis 
rested between a subretinal cvsticercus and chorioidal neoplasm. The case 
was that of a man, aged 20 years, whose vision had been failing for months. 
The ophthalmoscope showed a rounded elevation. Repeated examinations 
failing to show movement in the mass, the diagnosis of chorioidal tumor 
was ventured, and an enucleation was performed. The tumor measured 
eight by five millimetres, and extended from the ora serrata to the equator. 
Microscopic examination showed it to be a myoma of the chorioid. 

Ossification of the Chorioid is of very rare occurrence. Ossification and 
calcification in an intra-ocular exudate are not unusual conditions (see page 
422). 

INFLAMMATION OF THE CHORIOID. 

The term chorioiditis is a broad one, and is applied not only to cases 
in which the inflammation of the chorioid is actually in progress, but also 
to the lesions which exist long after the subsidence of the inflammatory 
process. A diagnosis of chorioiditis with the ophthalmoscope is possible 
only after the pathologic process has involved the retinal pigment-cells; 
hence, the condition is a chorioidoretinitis. From a clinical standpoint, 
cases in which the pathologic process begins in the chorioid are classed as 
chorioiditis, which is divisible into (1) exudative and (2) suppurative forms. 
In the former the eye is of normal appearance externally, and the diagnosis 
can be made only by ophthalmoscopy; in the suppurative form the iris 
and ciliary body are involved, and in violent cases the condition known as 
panophthalmitis ensues. Serous chorioiditis, formerly held to be the cause 
of glaucoma and of detachment of the retina, does not occur. 

Hyperemia of the Chorioid exists, but cannot be diagnosticated as a 
distinct condition, since its only ophthalmoscopic sign is increased vas¬ 
cularity of the optic disc, whose vessels anastomose with those of the 
chorioid. Hyperemia is attributed to eyestrain from uncorrected or im¬ 
properly corrected errors of refraction. In such cases the hyperemia of the 
nerve-bead disappears under treatment by atropin, rest, and colored glasses, 
or after the use of the proper correcting glass. 

Exudative Chorioiditis (Plastic Chorioiditis).—Chorioiditis may be 
localized or disseminated. There are no subjective symptoms peculiar to 
the disease. Hence the diagnosis must rest on the ophthalmoscopic findings. 


DISEASES OF THE CHORIOID. 


421 


Symptoms. —While there are no subjective signs characteristic of in¬ 
flammation of the chorioid, it is the rule that the patient complains of 
reduced visual acuity, the presence of specks or a mist before the eyes, and 
a feeling of heaviness in and about the eyes. Frequently there are subjective 
sensations of light (photopsiae) and distortion of images (metamorphopsia), 
due, respectively, to irritation and to a lifting up of the retina by the 
chorioidal exudation. Vision may be slightly or greatly reduced or even 
abolished, according to the proximity of the inflammation to the macula 
or to the dissemination of the process. Scotomata are frequently found. 
These subjective symptoms will suggest the necessity of an*ophthalmoscopic 
examination. 

The changes found in the fundus will depend upon the stage of the 
disease. In the early stage the alterations are slight; in the height of the 
exudative process they are more marked; and in the period of atrophy they 
are most striking. In the early stage there are found edema of the retina 
with the presence of minute, rounded, discrete, yellowish-white elevations 
situated beneath the retinal vessels. The elevations may be most numerous 
at the periphery; in fact, it is usually stated that disseminated chorioiditis 
begins at the periphery, but there are many exceptions, the macula often 
being the area first showing the disease. Simultaneously with the pouring 
out of the exudation into the chorioid there occurs a depigmentation of the 
retina over the involved area. Probably in all except the eyes of blondes 
this pigment destruction is necessary before the chorioidal exudate can 
become visible. Involvement of the retina is indicated by the presence of 
snowy-white or bluish-white areas; and when the retinal cloud is absorbed 
the chorioidal stroma is exposed to view. This change can be appreciated 
by comparing Fig.. 28G with Fig. 287, from Liebreich’s “Atlas,” showing 
the same fundus with an interval of ten months. Hemorrhage into the 
chorioid and hyperemia and swelling of the nerve-head are not common 
accompaniments of the early stage of chorioiditis. The process may stop 
here, the exudate undergoing absorption and the disease leaving few traces; 
but, as a rule, such a favorable result does not occur. The process goes 
onward, or, if checked, a fresh attack of chorioiditis ensues. Pigment is 
deposited over and around the exudation; or, as often occurs in the form 
of chorioiditis accompanying myopia, the chorioid undergoes extensive 
atrophy with only slight pigment deposition. In the stage of atrophy 
chorioiditis presents a striking picture, the denuded sclera being visible. 
If the process has become arrested while the exudation spots were small 
and discrete, in the atrophic stage the fundus will show small, white, cir¬ 
cular areas, each of which presents a pigment border. Frost states that this 
form of the disease occurs frequently in inherited syphilis, and is often first 
discovered when the cornea clears from an attack of interstitial keratitis. 
In exceptional cases there is no deposition of pigment in the atrophic stage. 
Where the disease is not arrested early, the atrophic spots merge into one 
another, and thus a large area of the sclera is exposed. Patches which ap- 


422 


MODERN OPHTHALMOLOGY 


parently have undergone complete atrophy may continue to enlarge with¬ 
out the advent of fresh exudation. In a late stage of chorioiditis masses 
of connective tissue form in the retina, simulating retinitis proliferans, in 
the latter, however, the exudation lies in front of the retinal \essels. Vitre¬ 
ous opacities may be found at any stage of chorioiditis. They are fiequently 
small and “dust-like,” particularly in the syphilitic form of the disease, 
but may be large and thread-like. They may be fixed or movable. The 
lens, at this stage, begins to show opacity, particularly at its posterior pole, 
from which strise radiate. Adhesions form between the iris and the capsule 
of the lens. The eye becomes soft at a late stage and detachment of the 
retina often occurs. The vitreous may shrink, drawing the lens backward 
w ith it and thus greatly increasing the depth of the anterior chamber. The 



Eig. 286.—Early stage of cliorioidoretinitis. (Liebretcix.) 


formation of bone is not unusual in such eyes. The term atrophy of the 
eyeball is applied to such shrunken globes. Keratitis punctata may be 
present at any stage of chorioiditis, indicating that the disease has reached 
the anterior portion of the uveal tract. 

Clinical Forms of Exudative Chorioiditis. —The classification of 
inflammations of the chorioid is an unsatisfactory matter. Ophthalmic 
writers have made many divisions, based either upon the location of the 
morbid process or on its supposed etiology. The following clinical forms 
are recognized:— 

1. Disseminated chorioiditis. 4. Syphilitic cliorioidoretinitis. 

2. Central chorioiditis. 5. Anterior chorioiditis. 

3. Myopic chorioiditis. 6. Chorioiditis with descemetitis. 

7. Gonorrheal iridochorioiditis. 




DISEASES OF THE CHORIOID. 


423 


1. Disseminated Chorioiditis (Fig. 2, Plate XIA 7 ) may involve one or 
both eyes; in the latter instance one eye is usually much more involved than 
the other. Scattered over the fundus will be found alterations whose appear¬ 
ance will depend upon the stage of the disease. In recent cases the fundus 
will show numerous rounded or stellate elevated patches of a yellowish-white 
or grayish color, over which the retinal vessels course. In old cases the spots 
will be whitish, from exposure of the sclera, with pigmented borders. The 
spots may coalesce to form large patches, which present a punehed-out ap¬ 
pearance. The disease is chronic, new patches being formed from time to 
time. In an eye which is studded with such atrophic spots central vision 
may remain good, if only the macula is spared. The optic nerve is affected 



Fig. 287.—Late stage of cliorioidoretinitis. (Liebreich.) 

in disseminated chorioiditis. In the early stage both the retina and nerve- 
head are hyperemic, while later they become atrophic. The papilla loses 
its clear outline, becomes of a dirty-grayish color, and the retinal vessels 
are fewer in number and much contracted. A T itreous opacities, dust-like 
or string-like, are frequently present. 

Forster, in 1S62, described a form of disseminated chorioiditis under 
the name areolar chorioiditis, in which foci appear in the macular region 
and subsequently others come at increasing distances therefrom. At first 
each focus is black; gradually the pigment is removed from the centre 
toward the periphery, and finally the spots become almost white. 

2. Central Chorioiditis .—Inflammation of the chorioid in the region 
of the macula may be found at any period of life. When bilateral and 
occurring in infants it has an injurious effect upon the mental development 



424 


MODERN OPHTHALMOLOGY. 


of the child. The eyes are amblyopic and nystagmatic; and the facial ex¬ 
pression is suggestive of idiocy. Older subjects will complain of loss of 
vision and the presence of a central scotoma. Ophthalmoscopic examina¬ 
tion shows the presence of an exudation in the macular area, if the ca^e 
is seen early; if examined at a later period, a large, white, atrophic area, 
bordered with pigment, is found. The disease, both in the infantile and 
the senile forms, is sometimes found in several members of a family. In 
elderly persons the ophthalmoscopic signs may consist of a round or oval 
area at the macula, presenting yellowish, erosion-like dots and pigmentary 
changes, minute hemorrhages, and crystals of cholesterin, or the macula 
may look as though salt and pepper had been dusted upon it. Hutchinson 
and Waren Tay described a condition of the fundus, known as “Tay’s 



chorioiditis,” or “central senile guttate chorioiditis,” in which the macular 
area is filled with closely set, pale-yellowish dots. This condition, which 
was supposed to be found only in middle-aged and elderly persons, has been 
observed at all ages, and is similar to punctate conditions found in the 
retina. It is to be distinguished from colloid disease of the macular region. 
Another form of central chorioiditis has been named senile areolar atrophy 
of the chorioid, in which, owing to atrophy of the pigment layer, the 
stroma of the chorioid and the curves and anastomoses of its vessels can 
be plainly seen. Such a case may present the vessels as atrophic white lines 
(sclerosis of the chorioidal vessels). The failing vision of elderly persons 
in whom the dioptric media are clear is often due to central chorioiditis; 
and this condition may be a cause of great disappointment after a tech¬ 
nically successful cataract extraction. 





DISEASES OF THE CHORIOID. 


425 


3. Myopic Chorioiditis. —While, for the sake of convenience, the term 
myopic chorioiditis (Fig. 2, Plate XVII) is retained, it should be under¬ 
stood that in the majority of cases of myopia with chorioidal changes the 
process is a mechanical one, producing atrophy, inflammatory symptoms 
being of rare occurrence. In axial myopia the antero-posterior diameter 
of the globe is elongated by thinning of the posterior segment of the sclera. 
Although a limited amount of small-cell infiltration is present, the chorioidal 
condition is not classed as inflammatory. The change in the sclera can be 
seen ophthalmoscopically and demonstrated microscopically. The fundus 
changes of myopia can be best considered under two heads: (1) posterior 
staphyloma and (2) myopic degeneration. 

(a) Posterior Staphyloma (Posterior Sclerochorioiditis). —This term 
is applied to a condition often accompanying myopia, the chorioid adjacent 
to the nerve-head becoming atrophic. The stretching of the sclera is indi- 



1 . 2 . 3 . 

Fig. 289.—Types of posterior staphyloma. (Galezowskt.) 
1, Superior staphyloma. 2, External staphyloma. 5, Annular staphyloma. 


cated by the appearance of a crescent which is usually found on the tem¬ 
poral side of the disc, but sometimes is seen interiorly, superiorly, or nasally. 
The crescent is made by the sclera, which has been stretched, and, since the 
chorioid cannot follow, the white sclera lies exposed. This explanation is 
questioned by Schnabel (see “Myopia” in Chapter XXI). The exposed 
part may assume a triangular shape, and then is called conus (Jaeger). 
This term, however, is confusing, and should not be applied to the condi¬ 
tion found in myopia, but should be reserved for that congenital anomaly 
in which the nerve-head does not fit accurately into the chorioidal aperture. 
If the atrophy of the chorioid spreads around the nerve-head, the condition 
is called annular staphyloma. Since the boundary between the nerve-head 
and the staphyloma is often ill defined, the beginner in ophthalmoscopy 
may mistake a staphyloma for an unusually large papilla. The differentia¬ 
tion between the two is made by the greater redness of the nerve-head. The 

















426 


MODERN OPHTHALMOLOGY. 


line separating the chorioid from the staphyloma is better defined, is 
irregular, and is often bordered with pigment. Ihe vessels emeiging from 
the nerve-head are often narrow, straight in their course, and look as if they 
were stretched. The fundus changes may be limited to the vicinity of the 
nerve-head, but generally are more extensive. Rarely posterior staphylo¬ 
mata are found in hypermetropic and emmetropic eyes. Ophthalmoscopic 
examination of a highly myopic eye with posterior staphyloma will show the 
“Weiss reflex.” This appears on the nasal side of the papilla, at a distance 
of several disc diameters, as a curved line which presents a narrow light 
* streak bordered by two dark lines (Fig. 2, Plate XX). Its presence indi¬ 
cates the existence of a posterior scleral ectasia. 

(b) Myopic Degeneration. —This term has reference particularly to 
those fundus changes which occur in and around the macula lutea. In 
cases of progressive myopia there is not only posterior staphyloma, but 
marked changes are present in the entire fundus; and in malignant cases 
the changes involve even the ciliary body, vitreous, and lens. Loss of 
pigment in the epithelial layer permits the chorioidal vessels to become 
visible. Accumulations of pigment are often found as black spots near the 
macula. Hemorrhages may appear in the same locality, and after resorp¬ 
tion large or small white areas bordered with pigment are to be seen. The 
fundus may present a tessellated appearance. Central visual acuity is 
much reduced. Opacities appear in the vitreous and lens (posterior polar 
cataract), and detachment of the retina sometimes occurs. 

J+. Syphilitic Chorioidoretinitis (Fig. 1, Plate XIV) will be considered 
in Chapter XV, under the term “Syphilitic Retinitis.” 

5. Anterior Chorioiditis. —This term is applied to that condition in 
which the anterior portion of the chorioid is the site of exudation. The 
changes may be readily overlooked unless this part of the eye is carefully 
examined with the ophthalmoscope. The most frequent causes of anterior 
chorioiditis are myopia and hereditary syphilis. Doubtless the disease fre¬ 
quently accompanies parenchymatous keratitis. In cases permitting an 
ophthalmoscopic examination the periphery of the fundus shows numerous 
rounded black spots. In elderly persons ordinary pigment changes are 
often found in the anterior portions of the chorioid. 

6. Chorioiditis with Descemetitis. —A. Hill Griffith has called attention 
to a form of chorioiditis occurring in young subjects, chiefly females, and 
characterized by the appearance of dust-like opacities of Descemet’s mem¬ 
brane. The disease begins suddenly wflth failure of vision of one eye and 
without external signs of inflammation. The iris is normal. Ophthalmo- 
scopically a patch of recent exudation, of a whitish or bluish-gray color, 
is found in the chorioid and retina adjacent to the optic disc. Fine opaci¬ 
ties are sometimes present in the vitreous, and shreds of fibrin may extend 
into it from the chorioidoretinal patch. The dots on DescemeFs mem¬ 
brane are supposed to be derived from the chorioid. The disease occurs 
chiefly in tubercular subjects. Ozena is a frequent accompaniment. In 


PLATE XHT. 

Eisaasas of tha Charioid. 


Fig. 1.— Syphilitics Cttariaidaratinitis. 



Fig, 3.—Dis3 3minatad Ciinrioiditis. 






tnx spriun 

rjiciTudl* ent in sssBEBiZi , r ,1,^.^ is 

_>k* 'b emerging from 
<;. is . aii ? look ae if they. 

> i> >r. •la'iliylo- 

Ophthaln&scopic 
. \ itr. t will show h e 
•illa, at 2 distance 
•- its -a narrow light 

a v ita presence uidi- 


iphthui: • • 
liter. {'< • i i 
to a t 

brake. 1 h 














crenee 


particularly to 




x;nla hates.. In 


, ei fiLnl ’ si nii d f'i crlZ j t: tJ±2lH:pi 2 .1' 

•i; /loina, but 
a u ••>. uffnt cases 

: j , Bl". IjO.rl 01 

■ ' oidal viv: b to become 
; ■:■):■>■ It e. 13 near the 

ii y. and after resorp- 
: i li< at ire. to be seeA. The 
^ ..1 ’ • < •, acuity is 

;. • (posterior polar 






! to that, condition in 
. of esndaiiom The 
i tin :'V‘ is carefully 
■ : causes of anterior 
■ . h. -h the di-ease fre- 
, .'or•no ting an 

vrjws numerous 
' changes are 




■ i l at.tent ■ on 
iy b males, and 
amruclTciiiO xsslainnrasBiG—^S Erl ; • mem- 

>■ a if one ere and 

O'-hi i.ilrno- 
:*ay color, 
1 .‘no. paci- 
tv extend 




i.a s mem- 
occurs 











PLATE 14 









DISEASES OF THE CHORIOID. 


427 


Griffith’s cases syphilis was not present. The prognosis is favorable, the 
disease disappearing under antitubercular treatment. 

7. Gonorrheal Iridochorioiditis .—Bull has described cases of inflamma¬ 
tion of the uveal tract which followed or were associated with gonorrheal 
arthritis. The ocular symptoms were severe, and included pain, photo¬ 
phobia, lacrimation, and great reduction in visual acuity. Ciliary injection, 
exudation into the anterior and the vitreous chambers, and increase of intra¬ 
ocular tension were noted. Vision, which may be reduced to perception of 
light, improves rapidly after the administration of antirheumatic remedies. 

Causes of Exudative Chorioiditis. —While many cases of exudative 
chorioiditis are doubtless due to syphilis, and others are attributed to rheu¬ 
matism, gout, tuberculosis, anemia, and other diathetic diseases, there 
remains a large percentage of cases in which no general disease can be 
detected. Trauma, in the form of penetrating wounds, operations, or 
blows without visible lesion, accounts for some cases. Occurring in young 
subjects who otherwise are in good health, chorioiditis must be attributed 
frequently to excessive use of the eyes in near vision, either with or without 
the proper correction of errors of refraction. Disseminated chorioiditis is 
sometimes an hereditary affection, and at times it is found accompanying 
congenital cataract. 

Woods, of Baltimore, states that among the causes of chorioidocyclitis 
are disorders of menstruation, intestinal affections, naso-pliaryngeal disease, 
and acute infections. 

Pathology. —At the beginning of the process Iryperemia and edema 
are present, and are soon succeeded by a serous or fibrinocellular exudation. 
This may be found between the chorioid and retina, on the surface of the 
retina, or in the vitreous humor. Exudation present in the vitreous humor 
may cause punctate opacities or membranous bands. Edema of the retina 
and hemorrhages are frequent accompaniments of chorioiditis. The acute 
stage is succeeded by a period in which the chief features are the formation 
of new connective-tissue fibres, the disappearance of the smaller chorioidal 
vessels, atrophy of the chorioid and retina, adhesion between these mem¬ 
branes, and the proliferation of pigment epithelium. The affected structures 
are then represented by a transparent cicatrix, which is bordered with pig¬ 
ment. 

Diagnosis. —The diagnosis of chorioiditis must be made ophthalmo- 
scopically. Often, however, it will be difficult to determine whether the 
pathologic process is chiefly in the chorioid or in the retina. Pigment 
aggregations resembling bone-corpuscles are always in the retina (Nettle- 
ship). Exudates attributed to the retina often cover the retinal vessels, 
while chorioidal exudates are situated under the retinal vessels. Accord¬ 
ing to Meyer, the retinal exudates are more opaque than are those of the 
chorioid, and their borders show fine radiating lines, corresponding to the 
direction of the nerve-fibres. In retinitis the retinal vessels are tortuous. 
In chorioiditis diffuse opacities in the vitreous humor may so veil the 


428 


MODERN OPHTHALMOLOGY. 


retinal vessels as to simulate retinitis. Differentiation between a recent 
chorioidal exudation and old atrophic spots is important. In recent chorioi¬ 
ditis the ophthalmoscopist can see an exudation of yellowish-white color, 
with ill-defined outlines. iSTo chorioidal vessels are visible. The retinal 
vessels pass over the exudation and are seen to bend. The points of exuda¬ 
tion are free from pigment. Cases of old chorioiditis show pure white 
atrophic areas of irregular outline, often with a border of pigment; fre¬ 
quently islets of pigment exist within the atrophic area, and in rare cases 
the migration of pigment continues until the spot becomes black. In such 
an event the movement of pigment is from the chorioid into the retina, as 
can be proven in microscopic sections. The remains of chorioidal vessels are 
sometimes visible within the white atrophic areas, and not infrequently the 
vessels show white, thickened walls, or complete obliteration, the vessels then 
appearing as white cords. Differentiation between coloboma and old cho¬ 
rioiditis may be difficult, especially between the rounded coloboma occur¬ 
ring at the macula and elsewhere and the isolated patch of chorioiditis. 
The history of the case and the fact that in coloboma other anomalies are 
generally present will aid in the diagnosis. In some instances only the 
pigment layer of the chorioid is involved in atrophy. The pigment grad¬ 
ually disappears, thus permitting the chorioidal vessels to appear and form 
a tessellated fundus. This type of atrophy is common in myopia, in glau¬ 
coma, and in retinitis pigmentosa, and is physiologic in old age. 

Prognosis. —Exudative chorioiditis is a serious disease, frequently 
ending practically in blindness produced by the recurrence of acute inflam¬ 
matory attacks. The disease will affect vision in proportion to the proxim¬ 
ity of pathologic changes to the macula. While complete recovery is never 
to be expected, the prognosis is much more favorable in the chorioiditis due 
to eyestrain occurring in young subjects than in chorioiditis due to syphilis 
or to unknown causes in old persons. 

Treatment. —A patient with exudative chorioiditis should be given 
atropin and should wear dark, smoked glasses to protect the eyes from bright 
light. Under these he should wear the proper glasses to correct his error 
of refraction. Use of the eyes for near work is to be prohibited. Except 
in severe cases of iridochorioiditis, confinement in a dark-room or in bed 
is unnecessary. In case chorioiditis occurs in young persons with eye- 
strain, who present no signs of syphilis, the internal treatment is limited 
to the occasional use of an aperient and the daily administration of fer¬ 
ruginous tonics. This plan of medication, combined with rest of the eyes 
for a period of several weeks, and the prescription of proper glasses, will 
often result favorably. This is particularly true of cases in which the 
exudation is limited in area. In cases of disseminated chorioiditis it is 
advisable to place the patient quickly under the influence of mercury, and 
preferably by inunction. Iron also is often required, and complete mental 
and physical rest is to be advised. In all recent cases atropin and dark 
glasses are to be used. Iodid of potassium is a valuable remedy, though 


DISEASES OF THE CHORIOID. 


429 


probably inferior to mercury. These internal remedies are to be continued 
in milder doses long after the exudation has disappeared. Patients in whom 
signs of syphilis are present will probably receive much more benefit from 
this plan of treatment than will those in whom the diagnosis of syphilis 
cannot be established. In non-syphilitic chorioiditis some surgeons report 
good results from the use of salicylates. Cases of chorioiditis are recorded 
in which no benefit followed mercurial inunctions, and great improvement 
was apparent after subconjunctival injections of bichlorid of mercury or the 
hypodermic injection of pilocarpin. In old cases of chorioiditis strychnin 
and galvanism may be tried. 

Purulent Chorioiditis is divisible into endogenous and ectogenous 
forms. The endogenous variety is of rare occurrence and is produced by 
the lodgment of septic emboli in the ocular vessels, by the transfer of 
meningeal inflammation, or by the transfer of inflammation in orbital 
phlegmon and in thrombosis of the orbital veins. The ectogenous form is 
of frequent occurrence. It follows upon ophthalmic injuries and operations, 
and is found after perforating corneal ulcers and in cases of iris-prolapse. 
The varieties of purulent chorioiditis will be discussed under the names, 
respectively, of “Endogenous” and “Ectogenous Panophthalmitis.” 

Endogenous Panophthalmitis (Metastatic Chorioiditis). —In¬ 
flammation of the chorioid by metastasis fortunately is of rare occurrence. 
It has been found during cerebro-spinal meningitis, typhoid fever, scarla¬ 
tina, puerperal fever, erysipelas, mumps, caries of the cranial bones, ulcerat¬ 
ing endocarditis, septicemia following surgical operations and compound 
fractures, and in the course of pneumonia due to influenza. The existence of 
purulent chorioiditis as a metastatic affection was established by Virchow 
in 1856. Both eyes are usually affected, one after the other. Bull, of 
New York, who has carefully studied six cases occurring in the course of 
grippe-pneumonia, and has made two autopsies, states that the microorgan¬ 
isms found in such cases are the staphylococcus albus and aureus, the strepto¬ 
coccus pyogenes, and the pneumococcus. Bacterial thrombi have been dem¬ 
onstrated in the vessels of the iris, ciliary body, chorioid, retina, conjunctiva, 
ocular muscles, and orbital tissue. 

Purulent chorioiditis occurring in the course of meningitis is attrib¬ 
uted to direct extension of the morbid process along the lymph-spaces of 
the optic nerve. It occurs chiefly in children, and in the course of epidemic 
cerebro-spinal meningitis. 

Post-partum metastatic chorioiditis usually appears between the sixth 
and fourteenth days after delivery, and is more frequently unilateral than 
bilateral. It is a sign of the gravest import. Often there is rapid loss 
of vision with little pain and few external signs of inflammation. Cir- 
cumcorneal injection, iritic adhesions, hypopyon, with slight pain, are soon 
followed by the symptoms of acute panophthalmitis, perforation of the 
globe, a discharge of pus, and shrinking of the eye. Of sixty-three cases 
collected by Axenfeld, twenty-two were bilateral. 


430 


MODERN OPHTHALMOLOGY. 


Symptoms .—The disease is announced by headache, vomiting, rise of 
temperature, pain in the eye and head, with the ordinary signs of iridocy¬ 
clitis, and rapid and total loss of vision. Intra-ocular tension is at first 
increased, but later becomes decreased. The disease runs its course in from 
three to six weeks and ends in blindness, with shrinking of the globe. 
Ophthalmoscopic examination very early in the case will show numerous foci 
of exudation into the chorioid and retina. In a few hours the media will 
be clouded. The vitreous will be filled with fine opacities, the fundus pre¬ 
senting a dense, yellowish reflex. Iritis, exudation into the pupil, chemosis, 
and sometimes exophthalmos rapidly follow. Early perforation at the cor¬ 
neoscleral junction is not uncommon. 

Diagnosis .-—The diagnosis of metastatic chorioiditis is not usually diffi¬ 
cult, provided the surgeon obtains the history of the case and makes an 
ophthalmoscopic examination. The more severe cases, with pain, iridocy¬ 
clitis, and conjunctival chemosis, are to be spoken of as examples of meta¬ 
static panophthalmitis, while those of less severity, in which the lesions are 
confined to the fundus, are known as cases of metastatic chorioiditis. 

In the case of children, when purulent chorioiditis follows meningitis 
or thrombosis of the orbital veins, the ophthalmoscopic picture may re¬ 
semble that of neuroepithelioma of the retina. Usually, however, the 
presence of iritic adhesions, diminished tension, the anterior chamber 
being deep at the periphery and shallow at its centre, together with shrink¬ 
ing of the globe and the usual absence of vessels upon the intra-ocular mass, 
will serve to distinguish pseudo- from true neuroepithelioma. The diag¬ 
nosis is further discussed in the chapter on the “Retina.” In case of doubt 
it will be best to excise the eye. 

Prognosis and Treatment .—Since metastatic chorioiditis occurs in the 
course of a grave systemic disease, often producing death, the prognosis 
is most unfavorable. If life is saved the affected eye usually remains 
blind. In some instances the chorioiditis due to meningitis runs a mild 
course and leaves the patient with a small amount of vision. Metastatic 
chorioiditis following puerperal septicemia gives a most unfavorable prog¬ 
nosis. Of nine cases observed by Hirschberg, all died; recoveries, how¬ 
ever, have been recorded by Kipp and Wood. Kipp’s case was unilateral 
and W ood’s was bilateral. In the stage of acute suppuration, in metastatic 
chorioiditis, Bull performs evisceration for the relief of pain, but advises 
against enucleation, owing to the possible danger of producing meningitis. 
The diagnosis, however, must be clear. Less heroic measures for the relief 
of pain are the application of hot compresses and the administration of nar¬ 
cotics. When the eye becomes shrunken, it should be removed, if tender to 
the touch. 

Ectogenous Panophthalmitis.— This term indicates an acute sup¬ 
purative inflammation of the eyeball caused by trauma, by infection fol¬ 
lowing the perforation of a corneal ulcer, or by infection following pro¬ 
lapse of the iris. In other words, the infection is from without. -Most 


DISEASES OF THE CHORIOID. 


431 


cases of panophthalmitis are the result of accidental injuries, such as pene¬ 
trating or lacerated wounds, with or without the lodgment of a foreign 
body. Exceptionally the disease occurs after operations made upon the 
eyeball for cataract, or glaucoma, or after an optical iridectomy. The 
frequency of such disasters will vary with the practice of different surgeons. 

Symptoms .—Ectogenous panophthalmitis is characterized by pain, 
rapid and total loss of vision, and the objective signs of an intense inflam¬ 
mation. The pain is often excruciating and involves the eye and the head. 
Constitutional disturbances, such as nausea and vomiting, chills, and rise of 
temperature, are present. In from twenty-four to forty-eight hours after in¬ 
fection the objective signs are unmistakable. The eyelids are swollen; the 
tissues supplied by the pericorneal and conjunctival vessels are intensely 
hyperemic; the ehemotic conjunctiva may protrude beyond the eyelids; the 



Fig. 290.—Panophthalmitis and orbital cellulitis. (W. T. Shoemaker.) 

cornea is cloudy and the aqueous is muddy or purulent. The iris is lustre¬ 
less, hyperemic, and adherent to the lens-capsule. The eye is tender to the 
touch, immobile, and shows some exophthalmos. The tension is increased 
until after the occurrence of perforation, which takes place at the site of the 
wound (Eig. 6, Plate XI). The globe shrinks and forms a small, deformed 
stump. If unchecked by operative intervention, the entire process occupies 
many weeks. If the infection begins in the depths of the eye after the lodg¬ 
ment of a foreign body, the aqueous and cornea may remain clear for some 
time and the iris may be movable. In such cases ophthalmoscopic examina¬ 
tion shows a yellowish deposit deep in the vitreous. With a dilated pupil a 
yellowish reflex is seen by ordinary inspection. 

Pathology .—Microscopic examination shows the chorioid and retina 
filled with round-cell infiltration, and in many cases these structures are 
obliterated, their place being occupied by areas of round cells, coagulated 


432 


MODERN OPHTHALMOLOGY. 


material, and pigment granules. The veins show thrombosis, the arteries 
contain emboli, and the smaller vessels present hyalin swelling. Various 
forms of streptococci and staphylococci are present. Macroscopically it 
will be observed that the enucleated globe scarcely resembles the eyeball, 
owing to the great thickening of the sclera. The separate structures of the 
eye have lost their individuality, and the thickened scleral cup contains 
pus, blood, and detritus. The thickening involves the sclera, the optic 
nerve, and its sheaths. Tenon’s space is obliterated by adhesion of the 
capsule to the sclera, and thus exophthalmos is produced. 

Diagnosis .—Ordinarily there can be no doubt about the nature of the 
disease. The history of the case will generally leave no question as to 
diagnosis. Chemosis of the conjunctiva and swelling of the eyelids due to 
purulent or to diphtheritic conjunctivitis will present a profuse conjunctival 
discharge. In panophthalmitis such a discharge is absent. Orbital phleg¬ 
mon, tenonitis, thrombosis of the cavernous sinus, and panophthalmitis all 
present swelling of the lids, conjunctival chemosis, exophthalmos, and 
immobility of the globe. Panophthalmitis, however, shows suppuration 





Fig. 291.—Section of a panophthalmitic eye. (Wuedemasn.) 

within the globe, while in the other affections, which have been mentioned, 
the anterior part of the eyeball is of normal appearance. 

Prognosis in panophthalmitis is distinctly bad as far as vision is con¬ 
cerned, but is favorable as relates to life and to the integrity of the other 
eye. Kecent experiments in intra-ocular disinfection which were made 
by Ostv alt upon rabbits, and some clinical observations by Haab, who suc¬ 
cessfully employed iodoform intra-ocularly to check suppuration, seem to 
show that the prognosis of panophthalmitis will be more favorable in the 
future than it has been in the past. 

Treatment .—A patient with panophthalmitis should be sent to bed. 
Anodynes should be given to relieve pain. Atropin should be instilled thrice 
daily and laxatives administered. If a foreign body is present, it should be 
removed. As regards the treatment of the eye, one of the following pro- 
ceduies ma\ be employed: (1) intra-ocular disinfection bv iodoform may 
be tried, (2) the suppurating eye may be regarded as an abscess and treated 
by incision, (3) incision may be combined with excision of the cornea 
and evisceration of the contents of the globe, or (4) an enucleation may 
be made. 

1. The introduction of small pieces (one and one-half to two milli- 


DISEASES OF THE C’HORIOID. 


433 


metres thick) of iodoform into the anterior chamber has been successful 
in curing intra-ocular infection which otherwise would have resulted in 
panophthalmitis and loss of the eye. If a foreign body is present it should 
first be removed. Haab's success has been confirmed by the experience of 
others (Goldzieher and Eoemer). The iodoform should be specially pre¬ 
pared by sterilization and is introduced by an instrument passed through 
a wound made in the cornea. The observations concerning this method of 
treatment are too few to permit of final judgment as to its value. 

2. Incision of the panophthalmitic globe relieves pain and shortens the 
duration of the disease. The globe can be opened with a knife, or, as 
de Lapersonne prefers, with the galvanocautery. The eye is treated like 
an abscess. 

3. Incision, with excision of the cornea and evisceration, is a favorite 
method with those surgeons who fear meningitis after enucleation. The 
cornea is removed and the interior of the eye is cleansed by forceps wrapped 
with gauze, thus removing the remains of the retina and uveal tract. 
Gauze is placed in the scleral cup and the eye is dressed daily. This method 
results in the formation of a small stump, over which an artificial eye can 
be worn. 

4. Enucleation in panophthalmitis is practiced by many surgeons, but 
is violently opposed by others on the ground that it may cause meningeal 
infection. While the author does not hesitate to enucleate panophthalmitic 
eyes, he feels the last word has not been said regarding this operation. 
Meningitis, however, has been known to occur after evisceration, and also 
has followed panophthalmitis which was not treated by operation. 


INJURIES OF THE CHORIOID. 

Wounds of the Chorioid occur in connection with wounds of the sclera, 
and should receive careful treatment. The chorioid should not be sutured, 
but the sclera and conjunctiva can be sewed, careful attention being given 
to cleanliness. Although the primary result may be encouraging, secondary 
retinal detachment often occurs. 

Foreign Bodies lodging in the chorioid should receive the treatment 
mentioned in the chapter on the “Sclera” (page 371). 

Chorioidal Hemorrhage may occur without rupture of the retina, as a 
result of trauma or idiopathically in the early stage of an exudative cho¬ 
rioiditis. The hemorrhage may be into the structure of the membrane or 
between it and the sclera. The blood forms a bright-red or brown, oval or 
circular spot, over which retinal vessels run. The blood gradually becomes 
absorbed, leaving a white, atrophic spot, with some pigmentation. Acute 
glaucoma may be produced by chorioidal hemorrhage. Differentiation be¬ 
tween hemorrhage into the superficial layers of the chorioid and that into 
the deeper layers of the retina is impossible. Hemorrhage into the nerve- 
fibre layer of the retina presents a flame-shape in marked contrast to the 

28 


434 


MODERN OPHTHALMOLOGY. 


rounded or oval patch of chorioidal hemorrhage. In a case of hemorrhage 
under the author’s care the condition was caused by a blow, and appeared 
as a circular black spot, one-eighth the size of the optic disc, situated imme¬ 
diately below the macula. Six years after the injury vision was 2 % 0 . 
The treatment includes rest, atropin, and smoked glasses, with diaphoretics 
and mercurials. 

Detachment of the Chorioid, aside from being caused by malignant 
tumors, is probably of much more frequent occurrence than would be sup¬ 
posed from the limited literature. It is caused by trauma, chronic inflam¬ 
matory processes with shrinking of the vitreous, chorioidoretinitis with 
adhesions between the two structures, and serous effusions between the 
chorioid and sclera. It may follow the sudden reduction of intra-ocular 
tension, and is one of the unfortunate accidents of glaucoma and cataract 



Fig. 292.—Ruptures of the chorioid. (Knapp.) 


The figure at the left shows a vertical tear at the left of the optic disc and an exudation 
at the right. The figure at the right presents two ruptures of the chorioid and a hemorrhage 
in the region of the macula. In both illustrations retinal vessels are seen crossing unbroken 
over the ruptures. 

operations. The detached portion forms a rounded, brown, smooth mass, 
resembling a vesicle, but without the folding and flapping of the mass 
which are features of retinal detachment. Secondary detachment of the 
retina may occur in these cases. Eyes in which the chorioid is detached 
often end in atrophy of the globe. The treatment of the condition is 
rest by atropin and the use of the bandage. 

Rupture of the Chorioid follows severe injuries, particularly con¬ 
cussions and blows with blunt instruments, but in many cases it arises from 
blows that are apparently insignificant ; and is often obscured by hemor¬ 
rhage into the vitreous. After this clears the tear in the chorioid can 
be seen as a long, narrow, often sickle-shaped separation. According to 
Knapp, it is rarely combined with laceration or detachment of the retina. 
It is usually found at the posterior pole, since here the chorioid is bound 
to the sclera by the entering ciliary vessels, and generally is found on the 



DISEASES OF THE CHORIOID. 


435 


temporal side. Its direction in most cases is vertical, although horizontal 
tears have been observed. The rupture at first is yellowish, but later becomes 
white. Its margins are bordered by pigment, and often the retinal vessels 
can be seen running across the break. The damage may end with the 
rupture, or the chorioid may undergo a chronic atrophic process. When 
located near the macula, rupture of the chorioid damages vision. Small 
ruptures are said sometimes to unite spontaneously; large ones always 
remain. The treatment, is atropin, aperients, the application of leeches 
to the temple, and rest. Often other lesions of the eye occurring at the 
same time are regarded as of greater moment, and many of these cases are 
diagnosticated as traumatic iridocyclitis, the rupture in the chorioid being 
either entirely overlooked or discovered late in the history of the case. 
There is often dilation of the pupil, paralysis of accommodation, hemor- 


Fig. 293.—Colloid change in the macular region. (De Schweinitz.) 

rhage into the vitreous, scotoma, and great reduction in visual acuity. Xot 
infrequently vision improves for some weeks after the injury and then 
becomes permanently bad, owing to contraction of the scar-tissue formed 
in the chorioidal gap: a fact which bears directly on prognosis. Detach¬ 
ment of the retina sometimes occurs late in these cases. 

Colloid Disease of the Macular Region.—A rare condition of the 
macular region, which is symmetric and which may be mistaken for cen¬ 
tral chorioiditis, is the occurrence of colloid formations resembling those 
found in the nerve-head. In a case observed by the author both maculae 
were occupied by rounded, yellowish bodies lying beneath the retinal ves¬ 
sels, and presenting a mulberry-like appearance, d he patches were oval 
and equal in length to two disc diameters. The patient was a man, aged 
41 years, and vision was normal. Three similar cases have been seen by 
de Schweinitz. Nettleship has described a similar case as central, guttate 













436 


MODERN OPHTHALMOLOGY. 


chorioiditis with normal vision. His patient showed “a number of small, 
perfectly circular, pale, grayish-yellow spots thickly congregated at the 
yellow-spot region, and more thinly scattered all around that part, reaching 
on the nasal side as far as the disc.” According to Dimmer, the change 
is a simple colloid degeneration. The excrescences are located in the lamina 
vitrea of the chorioid. The condition does not call for treatment. Cho¬ 
rioiditis can be excluded by the fact that vision is normal. 

Atrophy of the Eyeball.—Plastic inflammation of the uveal tract 
(iridochorioiditis) often ends in a condition in which the eyeball becomes 
soft and lessened in all its diameters. The globe is irregular in shape 
from wrinkling of the sclera. The retina becomes detached. When the 
exudation lies chiefly behind the lens, the anterior chamber will become 
shallowed. If the force of the contracting exudate is exerted more in a 
backward direction, the chamber will be deepened. The condition is known 
as atrophy of the globe, and is irremediable. Often the optic nerve also 
becomes atrophic. An atrophic globe, on section, presents the various 
tunics much altered. Such an eye may be tender upon pressure, and may 
cause sympathetic irritation or sympathetic ophthalmitis. If tender, the 
atrophic globe should be removed. 

Phthisis Bulbi.—This term is applied to shrunken globes in which the 
shrinking follows panophthalmitis with perforation of the sclera or cornea. 
The process is a rapid one, the diminution in size being brought about 
by a partial loss of the intra-ocular contents and by contraction of exudates. 
While in atrophy the altered membranes can be distinguished, in phthisis 
bulbi the retina and uveal tract are destroyed by suppuration. The stump 
in phthisis bulbi is usually small and innocuous. Hence an enucleation 
is not usually necessary. If, however, the stump is tender on pressure, it 
should be removed. As in atrophy, so in phthisis, the optic nerve becomes 
atrophic. 

Ophthalmomalacia (Essential Phthisis Bulbi).—An obscure and rare 
condition, which was described by von Graefe, is ophthalmomalacia. In this 
disease diminution of intra-ocular tension, pain, photophobia, miosis, partial 
ptosis, and rapid shrinking of the globe occur without hyperemia and without 
assignable cause. The disease may be intermittent and sometimes has fol¬ 
lowed injuries. It is probably dependent on a lesion in the sympathetic 
nerve. Fuchs states that the prognosis is favorable. Treatment must be 
limited to improvement of the general health. 


CHAPTER XIII. 


DISEASES OF THE CRYSTALLINE LENS. 

The crystalline lens is subject to congenital anomalies, to opacities, 
and to injuries. Being a non-vascular body, it is not liable to inflammation. 
It is greatly influenced by the state of the other ocular structures and by the 
general condition. 

CONGENITAL ANOMALIES. 

They generally consist in coloboma, microphakia, lenticonus, aphakia, 
luxation, and cataract. 



Fig. 294.—Binocular coloboma of the lens without coloboma of the iris or 

choi'ioid. (Author.) 


Coloboma of the Lens is a rare condition, about one hundred and fifty 
cases having been recorded. Generally only one lens is involved. In most 
instances the defect is in the lower inner part, which presents an irregular, 
ragged line, but exceptional cases have been recorded by Schiess, Lang, Bron- 
ner, and Payne, in which the defect was outward or upward and outward. 
Doyne described a case of coloboma of the iris and chorioid, with projection 
of the corresponding margin of the lens. Commonly, in lenticular coloboma, 
the iris and chorioid also show colobomata. Iridodonesis is often present, 
and the patient may show abnormities of other parts of the body. Gen¬ 
erally the refraction is myopic. Vision is much reduced and accommoda¬ 
tion is weakened or absent. 

The cause of coloboma is a subject of speculation. A rational view 
in regard to it is that of Treacher Collins. He attributes it to the absence 

(437) 










438 


MODERN OPHTHALMOLOGY. 


of adhesions between the pars ciliaris retinae and the lens-capsule in one 
part of its circumference in early fetal life. In consequence of this there 
is an absence of the suspensory ligament at that point. Hence, as the 
eyeball becomes enlarged, that part of the capsule to which the ligament 
is not attached is not held taut, producing a depression in that situation. 

The best treatment is the correction of the refraction. Search should 
be made for astigmatism. 



Fig. 295. —Lenticonus anterior. (Modified from Werster.) 

Microphakia.—Cases of abnormally small lens are extremely rare. 
Beik has reported one with iridodonesis in a rachitic infant. Hartridge 
has seen a brother and sister with small, transparent, and well-formed 
lenses. There is a space between the margin of the iris and the periphery 
of the lens, as is shown ophthalmoscopically with a dilated pupil. Treat¬ 
ment will depend on accompanying conditions. If the lens is opaque it 
should be needled. 



Fig. 296.— Lenticonus posterior in a buphthalmic eye. (Modified 

from Pergens.) 

Lenticonus.—This is a cone-shaped projection of the anterior, rarely 
of the posterior, surface of the lens. The refraction is myopic in the 
projecting area and hypermetropic in the surrounding part. A few cases 
are on record of lenticonus changing into lentiglobus. The disease is gen¬ 
erally unilateral. Anterior lenticonus is supposed to be caused by adhesion 
of the lens to the cornea in early fetal life, while the posterior form is 
explained by traction exerted by persistent fetal vessels. The anterior 
form can be seen by oblique examination and the posterior may be recog¬ 
nized by the peculiar shadow-crescents obtained by the fundus-reflex test; 
also by the double ophthalmoscopic images of the fundus. Knapp says 


DISEASES OF THE CRYSTALLINE LENS. 


439 


that on movement of the mirror blood-vessels and circles and crescents of 
light and shadow in kaleidoscopic movements will be seen. There is no 
particular treatment aside from the correction of the error of refraction. 
In cases of double lenticonus needling of one lens can be tried. 

Congenital Aphakia. —Cases of congenital absence of the lens are on 
record. Dunn has reported one with a central cord in the vitreous humor 
corresponding with the previous position of the hyaloid artery. 

Congenital luxation of the Lens (Ectopia Lentis) is often an heredi¬ 
tary condition, affecting numerous members of a family. The lens is 
usually displaced outward, from disturbance of the suspensory ligament. 
Luxation may exist in company with coloboma of the iris and chorioid, or 
corectopia may be present. The ophthalmoscope shows double images of 
the fundus. If the margin of the lens crosses the pupil it will appear as 
a dark border. The treatment of ectopia lentis consists in prescribing 
glasses. If the lens occupies the greater part of the pupillary area, the 
refraction is myopic. Search should always be made for astigmatism. If 
the lens is opaque, it should be removed by needling or extraction in accord- 



Fig. 297.—Congenital luxation of the lens. (De Beck.) 

ance with its condition. A few cases in which the lens remained in the 
vitreous chamber, attached to the optic nerve, have been reported. 


CATARACT. 

Cataract is an opacity of the crystalline lens, or of its capsule, or of 
both. It consists of three main types: capsular, lenticular, or capsulo- 
lenticular. It may be congenital or acquired. It is either traumatic or 
idiopathic, and may be partial or complete. It may be primary, or sec¬ 
ondary to disease or to an operation; symptomatic of a systemic disturbance; 
simple or complicated; juvenile or senile; .stationary or progressive; hard, 
soft, or fluid. It may be white, black, brown, or yellow in tint. The loca¬ 
tion of the opacity in the various forms is shown in Fig. 298. 

Senile Cataract (Gray, or Simple, Cataract). —This, is often called 
hard cataract, and appears generally after the forty-eighth year. Sooner 
or later both eyes become affected. There is a gradually increasing loss 
of vision. Often a “spiders web” appears before the eyes. If the opacity 
is central, the patient sees better on a cloudy than on a bright day. If 
the periphery of the lens is opaque, the reverse is true. In uncomplicated 



440 


MODERN OPHTHALMOLOGY. 


cases there is not any redness or pain about the eye. As a rule, the patient 
attributes his defective vision to faulty glasses, objects appearing as through 
a mist or smoke. In the early stages the lens is swollen, the refraction is 
increased, and often the patient can s'ee without glasses, giving a condition of 
so-called “second sight.” The increase in refraction may amount to 3 D. 
Commonly it is from 0.50 to 1 D. In some cases there is a transient hyper- 



A, Complete capsulo-lenticular cataract. 11, Anterior polar cataract. C\ Posterior polar 
cataract. I), Cortical cataract. E, Nuclear cataract. F, G, H, Various forms of lamellar 
cataract. /, Axial cataract. L, Traumatic rupture of lens-capsule with swelling of lens- 
substance. 


emia of the conjunctiva from eyestrain. Any continued redness of the 
corneoscleral junction must be looked on with suspicion, and will lead the 
examiner to seek for more than cataract. Monocular diplopia or polyopia is 
often present in the formative period. The anterior chamber is ordinarily 
of normal depth. It may be shallowed, and, if so, it indicates a swollen 
lens. If it is deepened, it shows that there is a small lens. In uncompli- 



Fig. 299.—Anterior capsular cataract of stellate form. 
(Von Ammon.) 


cated cataract there is not any tremulousness of the iris. The iris should 
respond to light. If it does not, search should be made for some causative 
reason, such as iritic adhesions, nervous disease, or morphinism. To the 
unaided eye the patient’s pupil appears dark in the early stage of cataract, 
or it may present the natural smoky hue of old age; later, except in the 
rare form of black cataract, the pupil becomes white, gray, or brownish. 








DISEASES OF THE CRYSTALLINE LENS. 


441 


The patient’s vision gradually diminishes until he can distinguish only 
light from darkness. 

Diagnosis.— Since the lens of the old person naturally has a smoky 
look, it is always unsafe to make a diagnosis of cataract by ordinary inspec¬ 
tion. In suspected cases it is of importance that a correct diagnosis be 
made early. The catoptric test, the ophthalmoscope, and oblique illumina¬ 
tion are all of value in the diagnosis. The catoptric examination is of 
value for the determination of the presence of the lens and the location of 
an opacity. It depends on the fact that when a light is held in front of 
a healthy eye three images of the flame are seen. The first and second, 
which are erect, are produced by the anterior surfaces of the cornea and lens, 
respectively; the third, which is inverted, is produced by the concave pos¬ 
terior boundary of the lens. The first and second move in the same direction 
as the light, while the third moves in an opposite direction. If the lens is 
opaque, the third image is lost, while the second becomes dimmed: if there 
is an absence of the deeper erect image, it indicates an opacity of the anterior 


A B 



Fig. 300.—Appearance of cataract. 

A, With reflected, and, B , with transmitted light. 


capsule. Properly to examine an eye for cataract a weak mydriatic is neces¬ 
sary, preferably a few drops of a 10-per-cent, strength solution of euphthal- 
min. A stronger mydriatic should not be used, since it may cause an attack 
of glaucoma. In the examination, light from a concave mirror should be 
thrown into the dilated pupil, from a point distant about one metre, or closer. 
If black strife or spots appear on the red fundus reflex, there is an opacity 
probably in the cornea, lens, or vitreous. The location of the opacity can 
be determined by the parallax test, by oblique illumination, or by direct oph¬ 
thalmoscopy. If the lens is almost wholly opaque, the red reflex from the 
fundus will be correspondingly reduced. If the lens is wholly ripe, the 
reflex will be absent. 

An incipient cataract may present numerous small, round, black dots 
instead of black lines on a red field. The condition of the fundus should 
be determined, if possible. If the cataract is mature there is no shadow 
between the lens and iris-margin, such as that shown in Fig. 301; and no red 
reflex when light is thrown directly into the eye. Glaucoma is sometimes 
called cataract, with fatal result to vision. 





442 


MODERN OPHTHALMOLOGY. 


In glaucoma there is corneoscleral redness, increased tension, a dilated 
pupil, and often a beginning opacity of the lens. A practitioner unfamiliar 
with diseases of the eye may call such a case cataract, advise the patient 
to wait until the lens is ripe, and thus consign the poor victim to blindness. 
Where the media are clear, the ophthalmoscope shows glaucomatous excava¬ 
tion of the nerve-head, with arterial pulsation either spontaneously present 
or produced by slight pressure. Pain is often present in glaucoma. 

Course. —Cataract is usually progressive, but may remain stationary 
for many years. This is particularly true of the cortical form. The period 
between incipiency and full maturity varies from one to three or more 
years. The opacities may begin centrally or peripherally as clearly defined 
lines or as dots scattered through the cortex. If a cataract becomes over¬ 
ripe and undergoes liquefaction, the nucleus becoming movable in the cap¬ 
sule, the condition is called a Morgagnian cataract. In these cases the 
iris is tremulous. Fatty and calcareous changes may occur in old cases. 

Etiology.— In many instances cataract must be regarded as a phys¬ 
iologic process which is incident to age. The frequent occurrence of 
chorioidal changes in so-called senile cataract is illustrative of pathologic 



Tig. 301.—Shadow of iris seen in unripe cataract. (Fuchs.) 

states which affect the nutrition of the eyeball. Not infrequently it stands 
in causative relationship with general disease, such as diabetes, nephritis, 
etc. Heredity, exposure to great heat, ergotism, arterial sclerosis, uric- 
acid diathesis, eyestrain, and traumatism are etiologic factors. Often the 
etiology of cataract will be in doubt. In some cases it must be attributed 
to the influence of several factors. 

Pathology. —As a general rule, the cataractous lens contains rela¬ 
tively less water and more solids than the non-cataractous. W. J. Collins 
believes that this dehydration, associated with opacification, is in no sense 
dependent upon changes which are the result of age, and has no relation¬ 
ship with the ordinary senile ones. The cataractous lens is lighter in 
weight and is smaller in size than the clear lens. Berzelius considered the 
chemic change in cataract to be a coagulation of albuminoids and an 
increase of salts, cholesterin, lecithin, fat, and extractives. In cataract 
the growth of lens-fibres stops; their separation occurs, producing spaces 
which become filled with an albuminous liquid. This fluid coagulates and 
forms granular masses, which are known as the spheres of Morgagni. Some 
of the lens-fibres become swollen and remain, while others are changed 

O 



DISEASES OF THE CRYSTALLINE LENS. 


443 


into vesicle-like cells. The lenticular epithelium thickens, and the cortical 
lens-fibres disintegrate, while the central fibres remain unchanged. 

Prognosis. —The condition of the other ocular structures, particu¬ 
larly the retina and chorioid, as well as the general health, have their 
influences on the outcome of cataraetous lenses. If the rest of the visual 
apparatus is healthy, the patient, even with a mature cataract, will be able 
to recognize the location of a distant light in every part of the visual field. 
If he suffers from disease of the external ocular structures, such as inflam¬ 
mation of the lids, conjunctiva, or lacrimal apparatus, this should be 
remedied before any operation is performed. Where iritic adhesions are 
present, an iridectomy should be made. The general condition of the 
patient is of importance and should be brought as near to normal as pos¬ 
sible before operation is undertaken. Age per so is not a barrier to suc¬ 
cessful operation. 

Treatment. —There are two indications: local therapy and general 
care. The constitution of the patient should be carefully studied, and 
errors in diet, method of living, etc., should be corrected. Often these 
subjects will receive benefit from a course of treatment directed to the 
intestinal tract. Their tendency to indoor life should be checked. In the 
early stages of cataract much benefit is derived from a proper correction 
of refraction. If the lens ripens slowly, in suitable cases one of the opera¬ 
tions for artificial ripening can be performed. The use of weak strengths 
of atropin often temporarily improves vision. There is no medicine which 
possesses the power of removing cataract. In suitable cases the cataract 
should be removed by an operation. 

Congenital Cataract.—Eyes affected with this condition may present 
a white pupil, in which case the condition is observed early. It may exist 
in the form of limited opacities presenting many variations, in which case 
the child may reach the school-age before visual acuity is markedly dimin¬ 
ished. The former type may be classed as complete congenital cataract, 
and the latter is spoken of as incomplete. 

Complete Congenital Cataract is to be treated by needling, as 
soon as observed, even as early as the fourth or fifth month. The pupil 
should be enlarged bv a weak mydriatic, a general anesthetic is to be admin¬ 
istered, and the anterior capsule is to be opened with a cataract-needle. 
Repeated operative procedures are safer than a single extensive one. At 
the first trial only a small opening in the capsule is to be made. After 
complete subsidence of all reaction the operation can be repeated. After 
operation the use of atropin is necessary. 

Incomplete Congenital Cataract presents many varieties. The 
following forms, which are to be attributed to disease of the fetus or to its 
faulty development, are observed:— 

(a) Axial cataract, the condition in which the opacity extends either 
partly or entirely through the lens in an antero-posterior direction. Other 
forms of opacity may coexist with it. 


44-1 


MODERN OPHTHALMOLOGY. 


(b) Anterior polar cataract, dependent upon adhesions of the pupillary 

membrane and capsule, or to inflammation. 

(c) Posterior polar cataract, existing as a small, white, pyramidal 
mass situated at a posterior pole of the lens, and due to a persistent h} aloid 
artery or to some preceding retinochorioidal disease. 

'(d) Zonular (lamellar) cataract, which is the most common variety, 
presenting many peculiarities in the form and location of the opacities, the 
tendency to its development being often hereditary and occurring in scrofu¬ 
lous, rachitic, or feeble subjects, the opacity existing in the layers lying 
between the nucleus and the cortex. 

(e) Punctate and stellar cataract, which have been occasionally ob¬ 
served. 

(f) Congenital central or nuclear cataract, which may exist alone or in 
^combination with other forms. 

(g) Coralliform cataract, which is a rare variety. 

Treatment. —If proper glasses give the patient sufficient vision to 
enable him to obtain an education and follow a vocation, operation is not 



Fig. 302. —Coralliform cataract. (Author.) 

to be considered, as often congenital forms of cataract may remain stationary 
for many years. The choice of operation lies among a simple iridectomy, 
lenticular extraction, and discission. The iridectomy should be made oppo¬ 
site the clearest part of the lens. If this procedure fails to improve vision, 
a discission or extraction must be done. In case only one eye is affected 
with incomplete cataract it is best not to operate, since the removal of the 
cataractous lens produces such inequality in the refraction of the two eyes 
that binocular vision is rendered impossible. There are cases in which the 
operation may be done for cosmetic reasons. 

Soft Cataract.—Independent of those opacities, which are congenital 
and remain unnoticed for long periods of time, there is a form of cataract 
which appears between the ages of fifteen and thirty years. In such subjects 
the lens has not formed a hard nucleus. In senile cataract the nucleus prac¬ 
tically remains unchanged. In youth it is prone to degenerative changes. 
It splits, liquefies, and possibly becomes absorbed, ending in calcification 
of lens debris, with capsular thickening. Often while a lens is undergoing 
degeneration, fat, c-holesterin, and lime, with a small quantity of water, 


DISEASES OF THE CRYSTALLINE LENS. 


445 


will be found in it. If much lime and considerable fluid be present, the 
lenticular opacity becomes milky in character, and is known as milky, or 
lactate, cataract. If the entire lens is calcified and shrunken, the condi¬ 
tion is named calcareous cataract. If intracapsular ossification be present, 
it is known as osseous cataract. If only a thickened capsule remains, it is 
given the name of membranous cataract. Ordinarily, the juvenile form 
of cataract appears as a large mass of a mother-of-pearl color. The patient 
may be apparently in perfect health or be the subject of diabetes. Some 
cases of juvenile cataract are probably due to some such condition as con¬ 
vulsions or a forgotten trauma. 

Treatment. —This varies according to the condition of the lens. If 
the lens be of normal dimensions, appearing as a whitish body which com¬ 
pletely fills the lenticular space, it should be needled several times at 
proper intervals. Usually absorption of the lens occurs with a good result. 
Here, as in other such operations in the young, the use of a cycloplegic and 
mydriatic is necessary both before and after the procedure. 

If the cataract is calcareous or membranous, abstraction of the mass, 
or an excision of the central portion of it, is the proper procedure, as ordi- 



Fig. 303.—Anterior polar cataract. (Yon Ammon.) 

nary discission will often fail. As it is well to have the patient com¬ 
pletely under control, it is advisable to employ a general anesthetic. As 
a rule, if the patient has one good eye, operation is not advisable except for 
cosmetic purposes. 

Traumatic Cataract.—As its name indicates, traumatic cataract usually 
arises from the penetration of some foreign body, with or without its reten¬ 
tion. It not rarely occurs from a blow which, at the time, does not produce 
any visible change in any part of the eyeball. Subsequently the lens 
becomes opaque. The injury may have been given to the anterior or pos¬ 
terior capsule, with or without rupture of the suspensory ligament. The 
entire lens may have been dislocated and may become opaque. If a foreign 
body carries infection with it, the case is much complicated, and may pass 
into a condition of panophthalmitis. A clean foreign body may lodge in 
the lens without exciting any trouble, being accidentally found years after 
should the patient be operated on for supposed senile cataract. On the 
contrary, a portion of the lens which was opaque immediately after the 
trauma may become transparent. 

There is a large number of cases, however, in which such an injury is 
followed by a non-septic type of inflammation. This is particularly true 




446 


MODERN OPHTHALMOLOGY. 


of injuries produced by thorns, and other sharp instruments, such as 
needles or knife-blades, in which the missile is withdrawn at the time of 
the accident. In a few hours the eye becomes red and injected. There is 
rapid swelling of lens-substance. At times there is a corresponding increase 
in intra-ocular tension, which, unless relieved, destroys the eye by secondary 
glaucoma. Usually there is great pain with corneoscleral redness and 
chemosis. 

Treatment. —In the acute type of traumatic cases it is necessary to 
employ a 1-per-cent, strength solution of atropin, sufficiently often to secure 
maximum dilation of the pupil. A weaker solution should be used for 
children. This reduces inflammation and prevents iritic adhesions. The 
repeated applications of hot wet cloths are useful for the relief of pain. 
Under no circumstances should any kind of poultice be applied to the 
eye. It is often advisable to remove all dressings and to protect the eye 
from light by dark glasses. If intra-ocular tension increases, an imme¬ 
diate operation for its relief will be necessary. In such cases it has long 





Fig. 304—Calcareous cataract. (Von Ammon.) 


been the practice of the profession to make a linear extraction, incising the 
cornea with a lance-shaped knife and removing the lens debris through the 
opening. For reasons which will be given at length in the latter part of this 
chapter, the extraction of acute traumatic cataract should be done through a 
large opening made with a von Graefe knife. This procedure enables the 
operator to remove all of the lens at one sitting. It does not bruise the tis¬ 
sues and gives better results than the linear operation. In cases in which 
there is not much increase of tension the inflammatory symptoms subside 
gradually under appropriate treatment. If the patient is young and all signs 
of inflammation have disappeared, the cataract can be needled. If the case 
be that of an adult, the lens can be extracted. 

Post-opeiative Cataiact. 1 Ins is another type of traumatic cataract 
In this there is an opacity which is either left after a cataract operation or 
appears at a later date. In ordinary extraction the anterior capsule is cut 
to permit egress of the lens. The cut edges retract, and, in favorable cases, 
leave an unobstructed area. Ordinarily the posterior capsule is not inter- 






DISEASES OF THE CRYSTALLINE LENS. 


447 


fered with. At times lens debris and proliferating cells of the anterior 
capsule may remain and form an obstruction to vision. This complica¬ 
tion requires a secondary operation in order to insure a betterment of vision. 
So frequent is the occurrence of this kind of obstruction that the delivery of 
the lens in its capsule, or a special treatment of the posterior capsule at 
the time of extraction or a few weeks later, has been advocated. In those 
cases of extraction in which vitreous humor is lost the posterior capsule 
is ruptured. In ordinary senile cataract the posterior capsule is so thin 
that at first it does not form any impediment to vision, but later, usually 
after one or two years, the opaque capsule materially reduces vision. It is 
this that has caused the belief that cataract returns after operation. 

Course and Diagnosis. —The changes occurring in a capsule after 
operation are these: The anterior capsule is drawn away from the pupillary 



F, Dense fibrin in the pupillary area. F', Fibrin behind the iris, which is of a lighter 
structure. F", Fibrin in the anterior chamber, i, Iris near the wound, i', Iris opposite 
the wound. C.B., Ciliary body. C\ Cornea. W, Wound of the cornea; the iris is caught 
between its inner lips. A.C., Anterior capsule. P.C., Posterior capsule. 


Fig. 305.—Anterior segment of a rabbit’s eye twenty-four hours after 
extraction of the lens. (Bates.) 


area and becomes adherent to the posterior membrane; the capsular epithe¬ 
lium and lens fragments are thus shut off from the action of the aqueous 
humor and the membranes become thickened. Adhesion can occur between 
the anterior capsule and the iris or the edge of the wound, and later the 
iris and ciliary body are dragged by the contracting membrane. A chronic 
iridocyclitis is started in this manner, and may end in atrophy of the 
globe. Fortunately, in most instances, the inflammatory process subsides, 
allowing the institution of operative treatment. More formidable cases 
are those in which the iris is drawn into the corneal wound, and iris and 
capsule are bound into a cicatricial mass. ‘The pupil is displaced and 
vision becomes much reduced. Such cases often terminate in iridocyclitis 
and detachment of the retina. In these cases, after all inflammatory symp¬ 
toms have disappeared, Kuhnt’s operation may be tried. In the diagnosis 
ordinary inspection shows a gray or whitish veil in the pupil behind the 




44S 


MODERN OPHTHALMOLOGY. 


iris, which is made more perceptible by the use of oblique illumination. 
A mydriatic is often useful in the determination of adhesions between the 
iris and membrane. 

Pathology. —In a series of experimental operations made on rabbits 
Bates studied the changes which are attendant upon the development of 
post-operative cataract. The posterior capsule, which was not thickened, 
was generally wrinkled or thrown into folds. He did not find that sec¬ 
ondary cataract was ever due to an opacity, thickening, or wrinkling of 
the lens-capsule, but attributes it to a development of new connective tissue. 
He found the first step to be an accumulation of coagulable fluid in the 
anterior chamber, which was followed by a deposition of fibrin. This was 
succeeded by new connective tissue. It is presumed that post-operative 
cataract in man is due to similar changes. Many authorities attribute 
post-operative cataract to the proliferation of epithelial cells in that por¬ 
tion of the anterior capsule which is not incised or removed at the time 
of the extraction of the lens. 

Treatment. —The treatment of post-operative cataract, which is me¬ 
chanical, will depend on the condition present. For ordinary membranous 
opacity the needle operation should be made with a Hay knife or a Ivnapp 
knife-needle. In case the iris and capsule are grossly adherent, and the 
pupil is drawn toward the site of the corneal wound, a more extensive 
operation, such as de Weeker’s or Kuhnt’s procedure, becomes necessary. 
In all operations for post-operative cataract two principles should be 
observed: First, the operation should not be undertaken until all inflam¬ 
matory signs have disappeared; and, second, the offending membranes 
should be cut, never torn, since tearing produces traction of the ciliary 
body, which often results in loss of the eye. Discission of simple cases 
is followed by glaucoma in 1 or 2 per cent. Fortunately, this form of 
glaucoma yields to iridectomy. 

Secondary Cataract is that lenticular opacity which is dependent upon 
pathologic changes taking place in tissues which are adjacent to the lens. 
The most common example is that which is seen in the cortical changes 
following neglected iritis, in which an exudate uniting the iris and lens 
is deposited on the anterior capsule. The resulting opacity is called 
accrete cataract. 

Secondary cataract is also caused by such conditions as iridocyclitis, 
cyclitis, chorioiditis, glaucoma, and intra-ocular tumors. In these diseases 
the lenticular disturbances are attributable to interference with the nutri¬ 
tion of the lens. In most cases treatment is useless. In the accrete type, 
if the tension of the eyeball becomes increased, operation is indicated. 

Complicated Cataract.—This condition arises when any form of cata¬ 
ract has some disturbing complication, such as some anomaly, inflamma¬ 
tory exudate, or traumatic disturbance, which may interfere with the usual 
process of ripening or may militate against a successful operation. In some 
cases the pupil appears black, giving the condition known as black cataract. 


DISEASES OF THE CRYSTALLINE LENS. 


449 


It is a rare form of lenticular opacit} 7 , which is difficult of diagnosis. 
There is a gradual loss of vision, although the ability to see to count lingers 
is often retained. As a rule, the fundus cannot he illuminated. Oblique 
illumination shows fine strife and a nacreous lustre. 

The pathology of black cataract is uncertain. While its color is sup¬ 
posed to be due to an infiltration of hematin into the opaque lens, both 
Collins’s and McHardy’s cases spectroscopically examined failed to show 
any blood-pigment. Its treatment does not differ from that of ordinary 
senile cataract. Because it has a large nucleus, the incision for the extrac¬ 
tion of black cataract must be of ample size. 

Diabetic Cataract, which is but one of the forms of consecutive cataract, 
is commonly attributed to the abstraction of water from the lens, this 
being due to the altered composition of the intra-ocular fluids. While this 
form of lenticular opacity is probably the best known of the ocular mani¬ 
festations of diabetes, the statistics as to its frequency differ much among 
various observers. It may occur at any period of life, and is generally 
bilateral. In young subjects, the lens being soft, there is a rapid develop¬ 
ment of the condition. In the old, by reason of the hardness of the lens, 
the process is sloiver and is less characteristic. In diabetic subjects the 
epithelium of the iris is much thickened and is easily loosened during 
operative procedures. Hence, during an extraction, the aqueous humor 
may suddenly become brown in color, from detachment of iris-pigment. 
Under proper dietetic and hygienic treatment such cataracts in adults may 
remain immature for long periods of time. According to Nettleship, the 
opacities may gradually disappear with the subsidence of the general symp¬ 
toms. Cataract may be the only ocular manifestation of the dyscrasia, 
though often there are retinal changes and vitreous opacities. Iritis is a 
complication to be expected after operation. 

Prognosis. —This is favorable. 

Treatment. —This will depend upon the condition of the patient and 
the state of the lens. In early cases, with beginning lenticular opacity, 
temporary correction of errors of refraction, regulation of diet, and the 
employment of internal remedies will sometimes result in checking the 
process. In children discission should be employed; in adults extraction 
should be preferred. After a technically successful procedure the visual 
result may be unsatisfactory because of degenerative changes in other parts 
of the eyeball. Diabetic coma may ensue, producing death several weeks 
after operation. 


OPERATIONS FOR CATARACT. 

This part of the subject may be divided into those procedures for the 
removal of senile, congenital, juvenile, and traumatic cataract, those for 
post-operative cataract, and operations for ripening. 

Preparation of the Patient.—This is important. A bath should be 
given the night before operation and the excretory tracts emptied. Any 

29 


450 


MODERN OPHTHALMOLOGY. 


abnormal condition, especially of the mucous membranes, should, if pos¬ 
sible, be removed. The field of the operation should be made surgically 
clean. This can be done by thoroughly washing the forehead, eyelids, and 
adjacent parts with soap and water, followed by a solution of bichlorid of 
mercury (1 to 2000). The conjunctiva is to be washed with the bichlorid 
solution after the anesthetic has been used and immediately before the 
operation is begun. The excess of fluid is reduced by gauze. It is not 



12 3 4 5 b 7 


Fig. 306.—Instruments for extraction of cataract without iridectomy. 

(Author.) 

1, Yon Graefe knife. 2, Angular cystitome. S, Fixation-forceps. 4, Spoon. 5, Spatula. 

6, Speculum. 7, Loop. 


advisable to permit the bichlorid solution to reach the interior of the eye¬ 
ball, since it may produce keratitis. All instruments, gauze, dressings, 
and solutions are to be boiled before used. The operator and assistants 
should be surgically clean. The patient’s hair should be covered with ster¬ 
ilized towels. It is presumed that the lacrimal apparatus and conjunctiva 
are healthy. If they are inflamed, it will be advisable not to operate until 
after inflammatory conditions have been cured. 






























DISEASES OF THE CRYSTALLINE LENS. 


451 


Choice of an Anesthetic.—In all operations for traumatic cataract 
with rapid swelling of the lens and inflammatory symptoms, chloroform 
or ether is to be employed. In elderly persons, who have little self-control 
and are likely to behave badly, a general anesthetic often becomes neces¬ 
sary. In operations on infants and children the use of chloroform is 
advisable. For the majority of patients cocain anesthesia will suffice. Al¬ 
though many surgeons employ a weak (4-per-cent, strength) solution, the 
author uses a solution of 10-per-cent, strength. Weak solutions do not 
abolish the sensitiveness of the iris. 

In patients in whom confidence can be placed, only a local anesthetic 


i 



Fig. '107.—Incision in cataract extraction. (Author.) 

(Original drawing by Du. R. W. Mills.) 

is needed. For this purpose the operator can choose between a 10-per-cent, 
strength solution of cocain and a 1-per-cent, strength solution of holocain. 
It is perhaps unnecessary to add that the glass part of the eye-dropper must 
have been boiled and the solution is not to come in contact with the rubber 
bulb. 

Extraction of Senile Cataract.—Extraction can be simple—that is, 
without iridectomy—or combined with iridectomy. The simple opera¬ 
tion will be described first. The necessary instruments are: speculum, von 
Graefe knife, fixation-forceps (provided with a catch which can be easily 
opened), cystitome, spoon, spatula, and, as reserve instruments, if needed, 
iris-forceps, scissors, and lens-scoop. Besides a nurse, the surgeon should 



452 


MODERN OPHTHALMOLOGY. 


have two trained assistants, one to attend to the handling of the instru¬ 
ments, the other to assist in the operation. The speculum is to be intro¬ 
duced into the conjunctival sac, the eye is to be held in one hand by 
fixation-forceps placed opposite the middle of the proposed incision, while 
the operator takes the knife in the other. He will stand either behind or 
in front of the patient during the operation. An upward section, which 
should include a little less than half the circumference of the cornea, is 
made in the apparent corneoscleral junction. The cystitome is used to 
cut the anterior capsule and the lens is gently delivered b} r means of the 
spoon. Any remaining cortex should be expressed by gentle movements 
of the spoon on the cornea directed from below upward. In difficult deliv¬ 
eries a spatula may be employed to press the posterior lip of the wound 
backward while the spoon is used in the manner mentioned. Any pieces 
may be removed by the blade of the spatula introduced into the anterior 
chamber. As a rule, efforts for the removal of cortex should be continued 
until the pupil appears black. The iris is replaced in the proper position 
by stroking with the spatula. The lips of the corneal wound are cleaned, 
the speculum is removed, and the lids are closed. A dressing of gauze cov¬ 
ered with a light bandage is applied to both eyes. The eyes are allowed to 
remain undisturbed for forty-eight hours unless pain occurs, in which 
case the dressing is removed. Cleanliness must be maintained during 
the after-treatment. To prevent reaction atropin should be used on the 
third day. If much cortex has been unavoidably left, the medicine may 
be used in appropriate cases on the second day. If healing progresses 
favorably, the bandage can be left off and dark glasses substituted at the 
end of ten days. If all goes well the unoperated eye need be bandaged 
for only three or fonr days after operation. Temporary glasses are ad¬ 
justed in four or five weeks. 

In all cases the knife must be sharp and the incision should be in 
the same plane throughout. (The author prefers the knife made by Weiss, 
of London.) The puncture is made at a point one-half millimetre above 
the horizontal diameter of the cornea, commencing at the temporal side. 
The cutting is done by a gentle sawing movement, care being taken that 
the point of the knife does not touch the skin of the upper lid. At the 
finish of the incision a conjunctival flap can be made, or, as the author 
prefers, the knife can be turned slightly forward and the cut finished in 
the cornea. During this procedure the operator should be careful not to 
make undue pressure with the fixation-forceps. The incision of the cap¬ 
sule (known as cystotomy) is best made by a bent cystitome, whose point 
is passed into the anterior chamber and pupillary area; next it is passed 
under the iris and a wound is made in the periphery of the lens correspond¬ 
ing as nearly as possible to the general direction of the corneal incision. 
Some operators prefer to make a crucial cut in the pupillary area of the 
capsule or to excise a triangular segment of the same. During the use 
of the cystitome care should be taken that it does not injure the iris. 


DISEASES OF THE CRYSTALLINE LENS. 


453 


Delivery of the cataract requires a series of graded pressures. These 
should be applied in such a way as to cause the lower part of the lens to 
tilt directly backward, thus turning its upper segment forward into the 
corneal wound. This done, the delivery is accomplished by gentle, con¬ 
tinuous pressure of the spoon. 

Extraction with Iridectomy is accomplished in the following man¬ 
ner : After the corneal section is finished, the iris is gently drawn through 
the corneal wound and a small piece including the sphincter is excised. 
While the surgeon, holding the fixation-forceps in one hand, gentty draws 
out the iris with the other, the cutting of the iris should be done by a 
competent assistant. The cystotomy, delivery, and dressing are made in 
the same manner as in simple extraction. 

Accidents During and Following the Operation.—As regards the in¬ 
cision, the knife may be placed too far back, close to the dangerous ciliary 
zone, or too far forward in the cornea. Under these circumstances it is 
best to withdraw the instrument, treat the eye aseptieally, and attempt the 
operation at a later period. If the knife is properly entered, but at the 
point of counter-puncture the conjunctiva is lifted up into a bleb by the 
aqueous humor, the section should be finished as if this had not happened. 
The knife mav engage the iris either on the same side as that of the 
puncture or on the side of counter-puncture. If this happen, an attempt 
should be made to disentangle the blade and complete the section. In the 
event that the puncture and counter-puncture are properly made, but the 
iris falls over the knife, the section of the cornea should be finished without 
regard to the iris; except for the anterior chamber filling with blood and 
causing pain, this accident does no harm. Should the corneal section and 
cystotomy be made, but the lens fail to be delivered, this means, for example, 
either that the corneal wound is too small (a grave mistake) or that the 
capsule is tough and has not been properly cut. Under such circumstances 
the cystitome should be reintroduced and the capsule cut, followed by 
gentle attempts at delivery. If such measures fail, the incision, should 
it have been too small, must be enlarged by a scissors or a knife. Should 
the lens be dislocated, an attempt should be made to deliver it by means 
of a wire loop. The forcing of a cataract through too small a corneal open¬ 
ing is likely to produce disastrous inflammation, while prolonged attempts 
for delivery of a dislocated lens do damage. Collapse of the cornea, fol¬ 
lowing the incision, is not infrequent. The operation should be continued 
as if this had not occurred. The entrance of air into the anterior chamber 
is of no importance. If it remains after the operation, it will soon dis¬ 
appear by absorption. 

Spontaneous delivery of the lens immediately following the incision 
* is a rare accident. Such a delivery is produced by spasmodic action of 
the extra-ocular muscles, and may be attended by loss of vitreous humor. 

Loss of vitreous humor, if small, usually does no harm, and is fol¬ 
lowed generally by excellent vision, for the reason that the posterior cap- 


45-A 


MODERN OPHTHALMOLOGY. 


sule has been torn. If a large amount is lost, the globe will collapse. 
When vitreous is expelled, the speculum should be removed at once. The 
protruding mass is to be snipped off with scissors and the eye closed. In 
cases where the vitreous humor protrudes so rapidly that the operator can¬ 
not use the scissors, the eye must be closed. A day or two later it may be 
found that the wound is approximated, no harm having been done, and 
small beads of vitreous will be seen floating in the conjunctival cul-de-sac. 
If so much of the humor has been lost that the eye collapses, the globe 
should be filled with normal salt solution. This procedure may save the 
eye. 

Prolapse of the Iris, coming immediately after a simple extraction, 
calls for an immediate iridectomy. If the prolapse occurs later and is 
noticed within forty-eight hours, the patient should be placed under the 
influence of chloroform and an iridectomy made. If noticed after strong 


12 3 4 



6 7 8 9 10 



Fig. 308.—Incision of the cornea in various methods of cataract 
extraction. (Nimier and Despagnet.) 

J, Daviel’s incision. 2, Jaeger’s linear extraction. S , Critchett’s linear extraction. 

4, Von Graefe's modified linear operation. 5, De Wecker’s incision. 6, Critchett’s. 7, Warmo- 
lont’s. S, Liebreich's. 9, Lebrun’s. 10, Kiichler’s incision. 

adhesions to the corneal wound have formed, it should be let alone. If 
the iris, after replacement during the extraction, shows a tendency to draw 
toward the incision, it should be replaced, making the pupil central, and 
a drop of eserin or arecolin should be instilled into the conjunctival sac. 
Eegardless of this indication some operators use miotics in every case of 
simple extraction. 

During the operation should a hemorrhage come from the cut iris 
or conjunctiva, it is of no moment. It may so obscure the capsule that 
it cannot be seen during the performance of the cystotomy. Expulsive 
hemorrhage from the depths of the eye, causing pain, and coming on during 
or shortly after a cataract operation, is a serious accident. In such a case 
oozing of blood from the dressings will be noticed. Such eyes generally 
require enucleation. Shock and delirium are rare post-operative incidents 
in cataract patients. They should receive appropriate treatment (hypo¬ 
dermic injections of morphin, gr. a / c , or of hyoscin, gr. 1 / 100 ). Epileptic 


DISEASES OF THE CRYSTALLINE LENS. 


455 


seizure, occurring during an extraction, is an unusual accident which is 
mentioned by Power. 

Peculiarities in the Healing Process. —Generally a few hours after the 
extraction there is a little burning or smarting pain, which rarely calls for 
an anodyne. Severe pain coming on at any time within four or five days 
after operation will be due to hemorrhage, iritis, herpes, gout, or suppura¬ 
tion, etc. 

If hemorrhage appears late and is not profuse, a hypodermic injec¬ 
tion of morphin should be given, the patient should be placed in the upright 
position, and the wound should be inspected. Some authorities advocate 
the opening of the corneal wound with removal of the blood by flushing the 
anterior chamber with a bichlorid solution. This advice is of questionable 
value. The careful cleansing of the conjunctival sac and of the lips of the 
wound, with full asepsis, may prevent suppuration and save a sightless 
globe. As regards that rare form of hemorrhage coming on after closure 
of the corneal wound, prophylactic treatment, with later needling, should 
be employed. 

Suppuration in the Corneal Wound. —Since the advent of clean 
surgery this complication is fortunately very rare. At the first dressing 
(some twenty-four to forty-eight hours after extraction) the color of the 
discharges on the dressing should be particularly noticed. If they be 
slight and of dark color, the eye may be said to be doing well. In such 
cases the eyelids need not be opened, unless it be thought best to begin the 
use of atropin early, as should be done where much cortex has been left 
behind. If the discharge be profuse, particularly if yellowish, and the 
upper lid is swollen, the lids should be opened and the wound inspected. 
If the edges of the wound are yellow, treatment to check the suppurative 
process must be promptly undertaken. The conjunctiva is to be washed 
with a warm bichlorid solution (1 to 4000), the edges of the wound are 
to be carefully cleansed with a stronger solution (1 to 400) of the same 
material, and atropin (1 per cent.) freely used. This plan of treatment is 
to be repeated twice daily. The employment of subconjunctival injections 
is of value in suppuration. For this purpose Darier recommends the fol¬ 
lowing solution: Cyanid of mercury, 1; acoin, 10; normal salt solution, 
1000. A few drops of this solution are to be injected beneath the con¬ 
junctiva three times a day. The acoin is added to render the injection 
painless. The injection should be made throijgh an iridized platinum 
needle attached to a clean syringe. Morphin is employed to control pain; 
salines for the bowels, with supportive treatment, are indicated. In eld¬ 
erly, debilitated subjects the salines should be used sparingly, and quinin 
and milk punch are appropriate. If in twenty-four hours’ time the eye 
is doing well, the same line of treatment should be continued; if the sup¬ 
purative process extends, it will be necessary to chloroform the patient, 
cleanse the wound, and irrigate the anterior chamber with a solution of 
warm boric acid. The application of the electrocautery to the sloughing 


45G 


MODERN OPHTHALMOLOGY. 


area becomes necessary. The atropin should be continued. The placing 
of an iodoform disc in the anterior chamber nas been proposed. Some 
authorities employ mercury freely by the mouth, or b} r inunction, or both 
(Schirmer, Herbert). Suppuration occurs at any time of the year. It is 
due to many causes, such as lack of cleanliness, rough handling of the eye, 
lacrimal disease, conjunctivitis, nasal disease, influenza, or lack of proper 
nutrition in the cornea. It usually occurs within the first three days; rarely 
after the fifth day. Pain is the danger-signal; the concomitant symptoms 
are cliemosis, edema of the eyelids, turbidity of the aqueous humor, hazi¬ 
ness of the cornea, and a profuse discharge of pus. It may end in panoph¬ 
thalmitis, or, in milder cases, the iris may be drawn toward the wound, 
the pupil be closed, and the eyeball be deformed by a cicatrix following the 
slough. In this latter type of cases an iridectomy is indicated after the eye 
becomes quiet. With careful attention to asepsis and skillful operating 
the condition will rarely happen. 

Iritis is a frequent complication. Though usually occurring on the 
fourth, fifth, or ninth day, it may appear at any time within two weeks 
after an extraction. It may be due to rough manipulation during the 
extraction, or to an improper toilet of the wound. If any cortex has been 
left behind, the early use of atropin may be useful. If iritis occurs, the 
medicine may limit the degree of inflammation. A 1-per-cent, strength 
atropin solution should be used several times daily. If the attack should 
be severe, a solution twice this strength should be employed. The re¬ 
peated application of cloths wrung in hot water are beneficial, or, if desired, 
dry heat can be applied by means of a Japanese hot box. In these cases 
it is advisable to dispense with all dressings, since they soon become wet 
and act as poultices. Dark glasses should be employed to protect the eyes. 

Keratitis is also observed after cataract operation. Formerly, when 
bichlorid solution was permitted to enter the anterior chamber, a keratitis, 
presenting a milky-white appearance in the posterior part of the cornea and 
materially reducing vision, was often observed. The striped form of kera¬ 
titis is a common condition after cataract operations. In this variety of 
keratitis numerous stride pass downward from the wound. The condition 
disappears in a few days without treatment. The formation of vesicles 
in the cornea is a rare complication; it is supposed to be due to lymph- 
stasis. It usually disappears in about two weeks’ time. 

Cyclitis may occur in eight or ten days’ time in a case that has done 
well. In this form of complication a zone of circumcorneal injection will 
be noticed. The pupil may be round and the iris movable. Vision may 
be good. Pain, principally at night, may ensue. The capsule becomes 
thickened and vision is reduced. The process may pass away without 
leaving any bad results, or it may increase and terminate in glaucoma. 
The treatment consists in the local use of atropin, with the general employ¬ 
ment of anodynes and sodium salicylate. Tension must be observed daily. 
If the eye becomes glaucomatous, an iridectomy should be made. 


DISEASES OF THE CRYSTALLINE LENS. 


457 


Spongy Exudation into the Antfrior Chamber may occur after 
extraction. It begins with pain and swelling of the lids and conjunctiva. 
The pupil becomes contracted and there is a turbid exudate like a cobweb 
situated in the anterior chamber. The condition disappears in about a 
week without treatment. 

Tardy Closure of the Wound is generally due to the presence of 
foreign bodies, such as the iris, pieces of vitreous, or tags of capsule in 
the wound. Barely it is caused by blepharospasm and spasmodic entropion 
of the lower lid. The anterior chamber may remain open for two or three 
weeks. The condition rarely leads to suppuration, to prolapse of iris, to 
infection, or to corneal opacity. Proper treatment consists in the applica¬ 
tion of compressive bandages. If complications occur, they must receive 
appropriate treatment. 



Fig. 309.—Cystoid cicatrix lined by atrophied iris-tissue, in an eye in which glaucoma 
followed cataract extraction. (Treacher Collins.) 

1, Tip of the iris. 2, Ciliary body. 3, The bulging cicatrix lined by atrophied iris-tissue. 

4, Sclera. 3, Cornea. 

Spastic Entropion of the Lower Lid occasionally is seen in old 
persons. In such cases the bandage should be dispensed with; the eyelid 
may be held in position with adhesive strips. 

Filtration Edema, from the subconjunctival escape of aqueous humor, 
may occur after the use of a large conjunctival flap. Such an edema is 
paler than the inflammatory variety, and is likely to gravitate to the lowest 
part of the conjunctiva. Aside from the use of the bandage, it does not 
require treatment. 

Acute Dermatitis, involving the eyelids and adjacent skin, has been 
observed by Herbert. It was attributed to a too free use of a solution of 
perchlorid of mercury, probably aided by bandaging. The use of a soothing 
ointment will be advisable. 

Cystoid Cicatrix. — A cystoid scar may appear after any form of 
trauma which opens the anterior part of the eyeball. It occasionally occurs 


458 


MODERN OPHTHALMOLOGY. 


as a vesicle bulging from the site of the corneal wound after cataract 
extraction. It appears as a semitransparent vesicle. It may rupture at 
intervals and deposit aqueous humor beneath the conjunctiva. It is prob¬ 
ably dependent upon the presence of a piece of capsular material that is 
caught in the wound, or, more often, is due to an incarceration of a part 
of the iris-tissue (either the sphincter or a surface attachment). Treacher 
Collins says that such cicatrices are lined by more or less atrophied iris- 
tissue. 

When a fold of iris becomes fixed between the lips of a corneal 
wound the iris unites with the sclerocorneal tissue. The conjunctiva heals 
over it, and later, in response to intra-ocular pressure, this spot of least 
resistance expands. Normally the iris is impermeable to fluids, but the 
expanded portion becomes atrophic. Breaks appear in the pigmentary 
layer, which is probably the most resisting to jluids. A thin, bulging 
cicatrix, lined by atrophic iris-tissue, is thus formed. Any excess of intra¬ 
ocular fluid breaks through and passes into the subconjunctival tissue. 
Such a scar produces irregular astigmatism. Eyes affected with cystoid. 
scars are likely to be lost from such conditions as iritis, iridochorioiditis, 
or iridocyclitis. Persistent cystoid cicatrix may be treated by dissecting 
a flap of adjacent conjunctiva, finding the minute fistula, and cauterizing 
it with the small point of the electric cautery. 

Secondary Glaucoma. —This is a rare condition after cataract ex¬ 
traction, more frequently following discission. After extraction with 
iridectomy, it arises from adhesion of the pillars of the iris coloboma to 
the cicatrix and the lens-capsule, thus interfering with the drainage of 
the eye. Appearing several months after a successful cataract extraction, 
glaucoma may be due to the development of an epithelial implantation 
cyst in the anterior chamber. 

Sympathetic Ophthalmitis is a rare condition appearing once in 
about eight hundred cases of extraction. 

Choice of Cataract Extractions.—Extraction with iridectomy is safer 
for the patient in the hands of the majority of operators, the simple extrac¬ 
tion requiring more skill. Those who operate only occasionally should 
make an iridectomy. Iridectomy is indicated if tension is increased, if 
the cataract is unripe or very large, if the patient is badly behaved, or if 
the iris is rigid: i.e., does not react readily to a mydriatic. In hospital 
practice, where the lower classes congregate, it is safer to make an iridec¬ 
tomy. In private practice, among more intelligent persons, simple ex¬ 
traction can be made. The great advantage of the simple operation is the 
retention of a movable iris. The great disadvantage is the frequent occur¬ 
rence of prolapse of the iris. This can often be prevented by the instillation 
of eserin or arecolin immediately after the delivery of the lens, or by an hypo¬ 
dermic injection of morphin, as advocated by Eugene Smith, of Detroit. 
The making of an iridectomy does not insure the eye against prolapse of thq 
iris, for often the edges of the coloboma become attached to the lips of the 


DISEASES OF THE CRYSTALLINE LENS. 


459 


corneal wound. The question is an individual one which each operator 
must decide for himself. As shown by numerous statistics, the results as 
regards vision are practically the same. 

Preliminary Iridectomy is always to be advised in case the patient has 
only one eye, or if complications exist or are to be expected. It is also to 
be advised in the extraction of lenses whose maturity is in doubt. A 
small portion of the upper segment of the iris should be excised through 
a corneal incision made preferably with a narrow keratome. Care should 
be taken to include the sphincter in the excised piece of iris. The extrac¬ 
tion can be undertaken four or five, weeks later. 

Should Both Eyes be Operated on at the Same Sitting?—At the pres¬ 
ent day, when transportation and clinical facilities are so well developed, 
it is generally unnecessary to operate on both eyes at the same sitting. In 
charity practice the double extraction may be necessary. The consensus 
of opinion among modern ophthalmologists is in favor of operating on only 
one eye at the first sitting. Generally the extraction of the second cataract 
may be undertaken several weeks or months later. In a patient whose 
lenses are of about equal maturity, and who resides far from skilled ophthal¬ 
mologists and will be unable to return, the surgeon should not hesitate to 
make the double operation. 

Other Methods of Extraction.—Many methods of extraction have been 
advocated. Only those will be considered which are thought to be of im¬ 
portance. 

Extraction m t ith the Ivalt Suture is a method of great value in 
critical cases. The suture is to be introduced before the corneal section 
is made and is to be tied after the lens has been delivered and the toilet 
of the eye completed. A short, sharp needle, curved on a short radius and 
without a cutting edge, is to be passed into the true corneal tissue, but 
not into the anterior chamber, about two and one-half millimetres from 
the limbus. The exit is to be made near the limbus. The needle is then 
to be passed into the episcleral tissue behind the limbus, leaving a loop of 
thread tivo inches long between the corneal and scleral portions. The 
incision having been made and the lens delivered, the toilet is to be finished 
and the suture tied. Eisley, of Philadelphia, employs this method in cases 
where loss of vitreous is expected or the iris is tremulous, or the lens dis¬ 
located, requiring the use of the loop. Often by this means protruding 
vitreous can be pressed back into the eye and iris-prolapse can be pre¬ 
vented. In complicated cases, particularly if the other eye has been lost, 
the suture may be employed. It is to be drawn tightly, and removed 
on the fourth or fifth day. Although Kalt employs it as a routine method, 
the corneal suture has found favor with American ophthalmologists only 
in some complicated cases. 

Extraction of ti-ie Lens in its Capsule would appear to be the 
ideal operation, since all tissue causing opacity is removed at one sitting. 
After making the corneal cut and iridectomy, the operator passes a scoop 


4G0 


MODERN OPHTHALMOLOGY. 


behind the lens and lifts lens and capsule out together. The frequent 
occurrence of loss of vitreous humor has led to the abandonment of this 
operation as a general procedure. It is now employed for the removal 
of hypermature, tremulous, and dislocated cataracts and those presenting 
a calcareous deposit. Often in these cases the capsule is tough and the 
suspensory ligament is relaxed. Although the name of Pagenstecher has 
been frequently associated with it, the method originated with Richter and 
Beer. 

The Suction Operation, in which the fluid lens is drawn by suction 

through a tube introduced into the anterior chamber, is dangerous and 

unnecessary. 

*/ 

Linear Extraction is open to the same criticism. In any case in 
which either of these operations seems indicated, the surgeon will do well to 
make a broad opening with the von Graefe knife and deliver the lens-sub¬ 
stance as in the procedure advocated for traumatic cataract. Efforts to force 
debris through the linear opening may end in destructive intra-ocular 
inflammation. 

Immediate Capsulotomy. —So frequently does the capsule become 
thickened after a successful cataract extraction that some operators have 
attempted to make an opening in the posterior capsule immediately after 
the delivery of the lens. In the hands of a skillful operator it may be the 
ideal procedure. After extracting the lens in the ordinary way and remov¬ 
ing all cortex, the operator introduces the point of a curved gold-enameled 
hook, made of malleable steel, which is passed on the flat into the anterior 
chamber behind the lower pupillary margin. The instrument is then 
turned backward, hooked into the capsule, drawn gently to the mouth 
of the incision, rotated on the flat again, and withdrawn. This procedure 
tears the capsule and permits the vitreous humor to come forward. Eox 
states that in patients in whom he performed this operation 15 per cent, 
required needling or capsulotomy with scissors, while of cases in which 
it was not performed 75 per cent, required later operations. The author 
lias tried this operation and is not favorably impressed with it. Recovery 
is slow and iridocyclitis is likely to be a complication. 

Varieties in tiie Capsulotomy. —Some surgeons remove a piece of 
the anterior capsule with Mathieu’s forceps, an instrument which has teeth 
on its lower surface. Eugene Smith, of Detroit, has long followed this 
method, and has devised a capsule-forceps. If the capsule be thin, a cen¬ 
tral piece is thus removed, leaving a black pupil; if thick, the capsule 
and lens may be dragged out together. An old operation, which is pre¬ 
ferred by few modern ophthalmologists, is incision of the capsule with 
the cataract-knife while the instrument is being passed through the anterior 
chamber. There are several objections to this method of capsulotomy: (1) 
the incision in the capsule may be too small, (2) aqueous humor may escape 
before the counterpuncture is made, and (3) in the case of a Morgagnian 
cataract the field may be obscured by the opaque fluid. 


DISEASES OF TIIE CRYSTALLINE LENS. 


4G1 


Extraction Without the Speculum is preferred by some operators, 
who steady the g'lobe with the fingers placed on the intervening lids, or 
the lids may be separated by means of retractors. By this procedure they 
hope to lessen the danger of prolapse of vitreous humor. If the patient 
is ill behaved, or the eye is deeply set in the orbit, the extraction should 
be made without the speculum. The lids are separated by the fingers of 
an assistant and the globe is fixed with forceps held by the operator. 

It may be advisable to use the speculum only while making the corneal 
section, removal of the instrument becoming necessary if the patient be¬ 
comes restless and squeezes the lids. An intelligent assistant can counter¬ 
act the patient’s effort by lifting the speculum away from the globe, thus 
preventing pressure on the eyeball. 

Delivery by Pressure of the Fingers against the Globe has been 
advocated, but is to be condemned because of the danger of producing in¬ 
fection. Instruments can be boilech; the fingers cannot b'e so treated. 

Wenzel's Method, which consists in the use of corneal and iris flaps, 
is of value in cataract with total posterior synechia. The knife, passed 
through cornea, iris, lens-capsule, and possibly through the lens, is made 
to emerge on the opposite side of the cornea. The tissues are then cut, 
a piece of the iris-capsule flap is to be excised with de Wecker’s pince- 
ciseaux , and the lens delivered. The operation is of value in those des¬ 
perate cases in which the whole posterior layer of the iris is adherent to 
the capsule. The loop, a sharp hook, or forceps may be required for the 
delivery of the lens. Loss of some of the vitreous humor is to be expected. 

Tyrrell's Drilling Operation, which is sometimes of value in 
the treatment of cataract with iritdc adhesions following sympathetic 
ophthalmitis, will be mentioned in Chapter XVIII. 

Dilation of the Pupil before Extraction is practiced by some 
operators, particularly by the English surgeons in India. 

Extraction of Immature Cataract.—While most surgeons delay the 
extraction until the lens has become ripe, and others approve of artificial 
ripening, there are those who favor extraction of immature lenses in per¬ 
sons about or above the age of sixty years. One of the strongest advocates 
of this practice is Schweigger, who has said: “At sixty years of age the 
lens is hardened in its entirety, whether cataractous or not, and whether 
the cataract is complete or not. The cataract and the induration are 
phenomena absolutely different; the one is pathologic, the other pln’sio- 
logic. Thus, in persons of sixty years who have lost the faculty of accom¬ 
modation, a cataract even incompletely developed may be removed without 
the opacities being reproduced, for it is certain that the lens can be re¬ 
moved entirely.” If, under these circumstances, extraction is undertaken, 
an iridectomy should be made and special attention should be given to the 
removal of cortical substance. If much cortex remains, iritis will be sure 
to develop. The use of atropin immediately after extraction will be advis¬ 
able. It should be used until all corneoscleral redness has disappeared. 


462 


MODERN OPHTHALMOLOGY. 


Some surgeons, of large experience in the extraction of immature 
cataract, advocate irrigation of the anterior chamber with a warm saline 
solution, immediately following the delivery of the lens. McKeown opei- 
ates in this manner: After the corneal section and a small iridectomy have 
been made, a fine hollow needle is introduced inside the capsule of the 
lens. Then a few drops of the solution are injected, by siphonic action, 
beneath the capsule. The cystotomy is then made and the lens-nucleus 
delivered. The cortical substance is then to be removed by irrigation. 

Scleronyxis, or Keratonyxis (Dislocation of the Lens; “Couching-").— 
This ancient operation, which has practically become obsolete, consists in 
depressing the lens into the vitreous body by means of a cataract-needle 
passed through the cornea or sclera. The operation as a routine pro¬ 
cedure justly has been abandoned by reason of its many sequelae. While 
the immediate effect of the dislocation of a cataractous lens is most bril¬ 
liant, the ultimate result is disastrous, the majority of patients becoming 
blind in a few years from detachment of the retina, iridocyclitis, glaucoma, 
chorioiditis, ‘hyalitis, etc. 

Recently Powers, of London, and Suker, of Chicago, have revived the 
operation, which is to be emploj-ed only in carefully selected cases. Suker 
considers the operation justifiable in the following conditions: Cataract 
in the insane, epileptic, hemophilic; in cases with tremulous iris or fluid 
vitreous humor without chorioiditis or retinitis; in incurable dacryo- 
cystoblennorrhea, or conjunctivitis; in extreme old age, with its attending 
infirmities; in patients with incurable bronchitis and cough; in cases in 
which, one eye having been operated and lost by suppuration, the indica¬ 
tions point to danger of the same disaster to the other eye; in shrunken 
and secondary cataracts; and in posterior dislocations with tremulous iris. 
While the author believes that this list is too long, he can conceive of cases 
in which depression might be justified and extraction not warranted. 
Extreme age alone is not a barrier to successful extraction and mild forms 
of insanity do not prohibit successful operations. In persistent dacryo- 
cystoblennorrhea excision of the diseased area, followed a month later by 
extraction of the lens, should be preferred. Nor can the failure of an 
extraction on the first eye be justly advanced as an argument for couching. 
The operation of couching, however, may be considered justifiable in vio¬ 
lently insane subjects; in.those epileptics who are subject to daily seizures, 
and in those cataract patients of advanced age who, being near death, wish 
to see the faces of their loved ones once again. 

The operation of couching requires a speculum, a fixation-forceps, and 
a cataract-needle. The pupil having been dilated, the needle is passed 
through the cornea to the upper border of the pupil and placed against the 
lens. Then gradually increasing pressure is used to rupture the zonula 
and force the cataract backward into the vitreous. If the needle becomes 
engaged in the lens it can be dislodged by slightly rotating the instrument 
on its axis. It can then be withdrawn without danger of the lens following 


DISEASES OF THE CRYSTALLINE LENS. 


4G3 


into the anterior chamber. The eye should be bandaged and kept at rest 
for a few days. Atropin should be used in the after-treatment. 

Operations for Juvenile Cataract. —In the complete opacity of con¬ 
genital and juvenile cataract discission is the proper operation. If a large 
part of the lens is clear a visual iridectomy should first be tried. Dis¬ 
cission, or the needle operation, requires a speculum, fixation-forceps, and 
two cataract-needles. The pupil having been dilated and the patient being 
under a local or general anesthetic, the same preparation of patient, 
operator, and instruments is to be employed as in extraction. The specu¬ 
lum having been introduced, the operator, holding the globe with the forceps 
in the left hand, with the right passes a cataract-needle through the cornea 
into the lens-capsule, making a crucial incision. The instruments are then 
to be withdrawn, more atropin is applied, the conjunctiva is washed with 
a bichlorid solution, both eyes are bandaged, and the patient is placed in 



Fig. 310.—Depression of cataract. (Agatz.) 

bed. Atropin is to be continued until all signs of irritation have dis¬ 
appeared. In favorable cases both eyes should be covered for four or five 
days. Care must be taken not to dislocate the lens by the employment of 
too much force, nor to open the capsule too extensively. Pain and iritis 
are to be overcome by atropin and heat applied as previously explained. If 
there is rapid swelling of the lens with the advent of increased tension, 
the cornea should be opened with the von Graefe knife and the lens deliv¬ 
ered as in the operation for traumatic cataract. Dunn claims that if the 
aqueous humor is permitted to drain away before withdrawing the needle, 
thus producing temporary minus tension, there will be no danger of glau¬ 
comatous symptoms following discission. The object of the needle opera¬ 
tion is to bring the aqueous humor into contact with the lens. Solution 
of lens-substance then occurs and absorption follows. It is far safer to 
repeat the operation several times at intervals of a month or more than 



464 


MODERN OPHTHALMOLOGY. 


to make too extensive an opening at one time. In the later stages, in 
cases where the posterior capsule is tough, two needles should be used, 
as shown in Fig. 311, thus avoiding traction on the ciliary body. While 
generally the needle operation gives excellent results, serious inflamma¬ 
tion and even loss of an eye may happen to the most careful surgeon. 

At what age should discission give way to extraction? In general 
terms it may be said that discission is rarely admissible after the twentieth 
year. In high myopia the needle operation is sometimes employed to 
cause absorption of a clear lens. This subject will be discussed in the 
chapter on “Befraction.” 

* Operations for Traumatic Cataract.—Where the lens is injured and 
swells rapidly, causing increased tension, it should be extracted by the 
method to be described. For years it has been the practice to employ the 
linear operation. Performed for the purpose of relieving undue tension 



Fig. 311.—Discission with two needles. 


and evacuating lenticular fragments, the nature of the operation is such as 
to diminish the first only temporarily and defeat the second frequently. 
The site of the incision in the linear operation precludes the possibility of 
removing all fragments of the swollen lens. The oblique course of" the 
wound, shown in Fig. 312, renders its patency .impossible while favoring 
its closure. Furthermore, the incision made with the keratome is often 
too short. Flap wounds of the cornea gape more than linear ones, the 
tendency to gape depending upon whether the wound traverses the tissues 
perpendicularly or obliquely. A perpendicular section can be made easier, 
safer, and better with the von Graefe knife than with a keratome. If the 
instrument passes obliquely through the cornea, the lips of the wound 
close like a valve. The closure is due to intra-ocular pressure. This force, 
in the linear operation (see Fig. 312), acts as strongly on the posterior 
lip (3) as the anterior (2). The wound must be made to gape before 






DISEASES OF THE CRYSTALLINE LENS. 


465 

lens-substance can be expressed. Gaping of the wound can be produced, 
not by pressure opposite the site of the incision, but by force applied 
peripherally to the wound (at 1 /. in Fig. 312). Such an operation is 
unscientific. In place of it, the author for several years has followed this 
procedure: The. patient being under a general anesthetic, the pupil having 
been dilated, a von Graefe knife is passed into and out of the cornea, as 
in the extraction of senile cataract. The incision includes nearly one-half 
the circumference of the cornea. Such a wound will permit the removal 
of all swollen lens-substance, and frequently it will obviate the necessity 
of an iridectomy. Attention to asepsis is imperative. Atropin drops are 
to be continued for ten days. 

Procedures for Post-operative Cataract.—Following a successful ex¬ 
traction the lens-capsule may become thickened. In the majority of cases 
this occurs at a period varying from a few months to several years. The 
result is a great diminution of vision. The remedy is to remove a central 
piece of the offending membrane, or to make an opening in it sufficiently 
large for visual purposes. The obstruction to vision may come from a 



Fig. 312.—Site of incision for traumatic cataract. (Author.) 

1, Site of incision in the author’s method of extraction in traumatic cataract. 2, 3, Site of 

incision in the linear operation. 

closure of the opening which was made in the anterior capsule at. the 
time of operation. Proliferation of the epithelial cells of the capsule 
follows, and thus a tough, gray membrane is formed. In another series 
of cases in which peripheral capsulotomy has been performed, both anterior 
and posterior capsules are thickened. In still another type adhesions exist 
between the iris and capsule, and subsequent contraction of the mass exerts 
injurious traction on the ciliary body. A grave form of opacity is that in 
which the pupil has been drawn into the corneal wound. The iris is then 
placed on the stretch, and a solid mass, composed of iris, capsule, and 
exudate, obstructs the view. The simple form of obstruction shows a black 
pupil by ordinary inspection, but oblique illumination reveals a delicate, 
wavy, gray membrane in the pupillary area. In this condition the follow¬ 
ing operation should be made: After dilating the pupil, preparing the 
parts as for an extraction, and anesthetizing the eye, the operator passes 
two very sharp needles through the cornea, as in Fig. 311. The points 
of the needles should be made to pass through the same opening in the 
capsule. Then, the handles being brought together, the needle points are 
separated, each needle forming a support for the other, so that traction 

30 





466 


MODERN OPHTHALMOLOGY. 


will not be made upon the ciliary body. The capsule should be cut, not 
torn. The needles are to be withdrawn, atropin used for ten days, and 
glasses prescribed after all signs of irritation have disappeared. If intra¬ 
ocular tension rises, a paracentesis of the anterior chamber should be made 
and the atropin should be replaced by a 2-grain strength solution of pilo- 
carpin used thrice daily. If the tension is not reduced, or again rises, a broad 
iridectomy should be made at once. This will reduce the tension. This form 
of gkucoma occurs in 1 or 2 per cent, of needle operations. Another 
danger is infection, which occasionally destroys an eye after this procedure. 

Instead of employing the needle operation, Callan pierces the cornea 
and capsule with a long, narrow keratome. After withdrawing this instru¬ 
ment de Wecker’s scissors is to be passed into the eye, one blade being in 
front, the other behind the capsule, which is then to be cut. Thus a 
T-shaped aperture is made. If the capsule is not unduly tough, a clear 
pupillary area can be obtained by the use alone of the long angular 
keratome. This is passed through the cornea and capsule, and, while still 
in situ, is made to move from side to side, thus producing a larger capsular 
opening. This procedure requires a very sharp instrument. It is not 



Fig. 313. —Operation for post-operative cataract. (Kuhnt.) 

applicable to thick, tough capsules, and can be employed only with the 
pupil dilated. As in other similar procedures, atropin is to be used in the 
after-treatment. 

In those serious cases of post-operative cataract, where the iris has 
been drawn into the corneal wound and a dense membrane fills the pupillary 
area, a more radical operation will be necessary. The best procedure is to 
make a large corneal opening and with de Wecker’s scissors cut out as 
large a section of the membrane as possible, always avoiding traction on 
the ciliary body. Among numerous operations suggested for this purpose, 
that of Kuhnt is one of the most valuable. A cataract-knife passed through 
the cornea, iris, and membrane is brought out on the opposite side, as 
shown in Fig. 313. Then with the de Wecker scissors a large part of the 
obstruction is to be excised. 

_ Artificial Ripening of Cataract—Some cases of binocular cataract 
may ripen very slowly, necessitating a long period of waiting, which may 
be injurious to those who are wage-earners or those who have business 
interests. In such cases, the other parts of the eye being in good condi¬ 
tion, there should not be any hesitation to ripen the lens. For the per¬ 
formance of this procedure the pupil should be dilated by a mydriatic. 










DISEASES OF THE CRYSTALLINE LENS. 


467 


The anterior chamber is to be opened with a keratome and the lens is to be 
triturated by means of a small spatula. In a few weeks’ time the arti¬ 
ficially ripened lens can be extracted. This operation is not of value in 
posterior polar cataract, in slowly sclerosing lenses with few strige, and in 
the slowly forming cataract of myopia. 

Operations for Artificial Eipening. —Numerous procedures have 
been devised for the artificial ripening of cataract. They can be tabulated 
as follows:— 

1. Simple division of the anterior capsule. 

2. Division combined with iridectomy: Mooren’s operation. 

3. Division and external massage. 

4. Iridectomy and external massage: Forster’s operation. 

5. Iridectomy and internal massage directly on the anterior capsule: Bettman’s 
operation. 

6. Simple paracentesis with indirect massage: White’s operation. 

7. Paracentesis with direct massage. 

8. Injection by the Pravaz syringe of fluid beneath the anterior capsule: Joeqs’s 
method. 

The question arises: Which one of these is the best operation ? Before 
performing any of these procedures the operator should know that the 
zonula is intact, the tension not below normal, and the pupil dilatable. 

1. Simple division of the anterior capsule is condemned by all authori¬ 
ties on account of the inflammatory changes which follow a rapidly swelling 
lens. These are not only iritis, but also panophthalmitis. The most experi¬ 
enced ophthalmic surgeon cannot always tell when a wound of the lens 
will be followed by a dangerous reaction. The opening in the capsule 
may be too small. The surgeon may lacerate the fibres too extensively 
and cause the lens to swell too rapidly. Sometimes the result is entirely 
negative, the operation causing a plug of cortex to be squeezed out of the 
capsular wound, which afterward closes. The same objections obtain in the 
case of (2) division combined with iridectomy and (3) division with 
external massage. 

4. Iridectomy and external massage is the operation formerly most 
frequently performed, and is to be preferred to any procedure in which 
the capsule is divided. However, there are some objections to it. To 
those who prefer the simple extraction, the iridectomy would be a serious 
objection. Although the pupil is dilated by atropin before commencing 
Forster’s operation, some fibres of the iris are likely to be pressed between 
the lens and cornea, thus causing iritis. Mittendorf has recorded the loss 
of an eye. It must be remembered that the cornea also is being triturated, 
and its epithelial coat may be rubbed off. Forster himself has called atten¬ 
tion to the danger of injury to the cornea and iris, and to the possibility 
of producing a dislocation of the lens. The danger of dislocating the 
lens pertains as well to other operations for artificial ripening. 

5. The operation of direct massage is the best procedure. It can 
be done with (5) or without (7) iridectomy. The trituration is made 


468 


MODERN OPHTHALMOLOGY. 


directly upon the lens-capsule. The iris is not compressed; hence the 
danger of iritis is less than in Forster’s operation. The percentage of 
successes will be found to be greater than in any operation where the mas¬ 
sage is indirect. 

6. White’s operation, or paracentesis and external massage. The same 
objection (danger of compressing the iris) as that applied to Forsters 
operation also obtains here. 

7. For the Bettman operation these instruments are needed: speculum, 
fixation-forceps, keratome, iris-forceps, scissors, and spatula. The spatula 
is made of aluminum. It is twenty-eight millimetres long and one milli¬ 
metre wide. The cornea is to be opened by means of the keratome, the 
iridectomy made, and gentle massage applied by passing the spatula into 
the anterior chamber under the iris and on the anterior capsule. Ten or 
twelve movements will suffice. Atropin is to be continued for a week. 
Three or four weeks later the extraction can be made. 

8. Jocqs’s method is new, and has not been sufficiently tested to permit 
an opinion as to its value. 

Refraction after Extraction.—Removal of the lens leaves the eye 
aphakic. To secure good vision, a convex lens must be placed in front of 
the eye. To this must be added a convex glass of about three dioptres’ 
strength in order that the patient may read. To glasses both for far and 
near work there must be added a cylinder to correct the astigmatism remain¬ 
ing after the operation. This averages about three or four dioptres. The 
astigmatism following cataract extraction is greatest immediately after the 
extraction and progressively diminishes for six or eight weeks or longer. 
In some cases there is a further normal reduction in astigmatism, and 
glasses must again be prescribed at the end of six months. Here, as else¬ 
where, the estimation of the amount of astigmatism, and the determination 
of the axis at which the cylinder is to be placed, is much simplified by the 
use of the astigmometer. 

Results of Cataract Operations.—Statistics compiled from the reports 
of skillful surgeons show that the result of cataract extraction is the restora¬ 
tion of a useful amount of vision in 95 per cent, of uncomplicated cases. Of 
the remaining cases, 3 per cent, will have perception of light; 2 per cent, 
will be totally blind. In tabulating their cases, ophthalmic surgeons con¬ 
sider vision of 20 / 200 , or better, to be a good result. Vision from 1 / 200 to 
18 / 2 oo is classed as a moderate result, while cases possessing only perception 
of light are classed with the totally blind as failures. 

Spontaneous Cure of Cataract.—Spontaneous disappearance of senile 
cataract occurs so rarely that the surgeon is not justified in mentioning 
it to a patient. Brettauer, in 1885, reported three cases of spontaneous 
absorption of senile cataract, with restoration of vision, in all of which 
he had removed a cataract from the fellow-eye. In these cases there was 
no sign or history of injury, operation, or disease. Pyle has classified the 
reported cases as follows:— 


DISEASES OF THE CRYSTALLINE LENS. 


* 469 


1. Cases of absorption after spontaneous rupture of the anterior or posterior 
capsule. 

2. Cases of spontaneous dislocation of the cataractous lens. 

3. Cases of intracapsular resorption of the opaque cortex and sinking of the 
nucleus below the axis of vision, after degenerative changes in Morgagnian cataract, 
without rupture of the capsule or dislocation of the lens. 

4. Cases of complete spontaneous resorption of both nucleus and cortex with¬ 
out reported history of ruptured capsule, dislocation, or degeneration of the 
Morgagnian type. 

5. Cases of spontaneous disappearance of incipient cataract without degenera¬ 
tive changes or marked difference in the refraction. 


DISLOCATION OF THE LENS, ETC. 

Acquired Dislocation of the Lens may occur from trauma or spon¬ 
taneously. If from trauma, the other structures of the eye may be seri¬ 
ously injured simultaneously. The lens may be thrown backward into 
the vitreous body, or forward into the anterior chamber. It may pass 
through a corneoscleral rupture into a bed beneath the conjunctiva, or into 
the capsule of Tenon, or may be extruded entirely from the eye. At 
present only dislocation without rupture of the globe will be considered. 
Spontaneous dislocation occurs in cases in which a congenital defect or 
acquired disease has weakened the zonula of Zinn. Atrophy of the zonula 
may result from liquefaction of the vitreous, chorioiditis, high myopia, or 
detachment of the retina, and is not infrequent in hypermature cataract. 
The zonula being weakened, a slight disturbance, such as coughing, sneez¬ 
ing, or bending over, will suffice to cause a dislocation. The lens may 
completely leave its bed, luxation; or it may remain partly in place and 
be tilted forward or backward, subluxation. Dislocation into the vitreous 
humor is more frequent than into the anterior chamber. If the vitreous 
is softened, the lens can be seen bobbing about whenever the eye is moved. 
A misplaced lens becomes opaque, but in the vitreous it may retain its 
transparency for a long period. It acts as a foreign body and can cause 
serious trouble. The uveal tract becomes irritated, and such eyes often 
end in iridochorioiditis. If dislocated into the anterior chamber, the'lens 
may block the drainage apparatus, causing pain, increase of tension, and 
destruction of vision. In subluxation the patient is likely to be myopic. 
The zonula having lost its power over the lens, the latter by its elasticity 
gains greater curvature, thereby increasing the refraction. 

Diagnosis. —A partly dislocated lens, if clear, may cause monocular 
diplopia. When the lens is in the vitreous humor, the anterior chamber 
looks deep; the iris is tremulous, accommodative power is lost, the pupil 
usually is enlarged, and often the dislocated lens can be seen by the naked 
eye. To the ophthalmoscope the eye is markedly hypermetropic and the 
lens can be found as a dark, grayish body, constantly shifting its position. 
When in the anterior chamber, the lens, by ordinary illumination, appears 
of a golden or amber color much resembling a large drop of oil. It may 


470 • 


MODERN OPHTHALMOLOGY. 


wander from the vitreous to the anterior chamber in response to the 
position of the eye. It may remain for weeks in the anterior chamber, 
setting up great inflammation, and suddenly be found in the vitreous. 

Prognosis. —An eye with its lens located in the anterior chamber, 
and without other lesions, offers a favorable prognosis. If glaucomatous 
symptoms have appeared, the outlook is not so favorable, although it is 
surprising how well some apparently desperate cases will do after removal 
of the irritating body. A dislocation into the vitreous, if recent, may 
offer a good prognosis, provided the surgeon can .succeed in getting the 
lens into the anterior part of the eye, from which it can be extracted. An 
old dislocation, with a fluid vitreous humor, offers little encouragement. 

Treatment. —The proper treatment is extraction. If the lens is in 
the anterior chamber, removal will be easy. The first step will be the 
anchorage of the lens. A local anesthetic is to be used and a speculum 
introduced. The lens is to be fixed by passing an ordinary straight sad¬ 
dler’s needle, held in a Sand needle-holder, through the cornea. Then 
with a von Graefe knife the cornea is to be opened as in the ordinary 



Fig. 314.—Dislocation of the lens into the anterior chamber. 

(Von Ammon.) 

extraction. A wire loop is to be passed behind the lens, which is then 
delivered. The use of the bident is not necessary. The treatment is the 
same as that employed after a cataract operation. If the lens has caused 
great inflammation, or if the patient is a child, a general anesthetic will be 
necessary. It should be given with the patient placed face downward. 
Otherwise, when ready to operate, the surgeon may find that the lens has 
passed into the vitreous humor. It may be advisable to anchor the lens 
under holocain or cocain and deliver it under chloroform. If it is situated 
in the vitreous chamber, attempts to remove it are not justifiable unless 
its position can be changed. A\ ith the pupil dilated and the patient placed 
face downward, the lens may drop into the anterior chamber, in which 
event eserin should be instilled immediately, in the hope that the contract¬ 
ing iris will hold it in position until it can be anchored. In these cases, 
owing to the great danger of loss of vitreous humor, it will be advisable 
to make use of the Ivalt suture. If an eye containing a lens located in 
the vitreous humor is blind and painful, an enucleation should be made 
to prevent the occurrence of sympathetic ophthalmitis. 




DISEASES OF THE CRYSTALLINE LENS. 


471 


Parasites in the Lens.—The parasites which have been fonnd in the 
lens are filaria, monostoma, and distoma. The filaria, filaria lentis, is a 
species of which the female has been found several times in cataractous 
lenses. It measures from one to three millimetres in length. For obvious 
reasons it is found in hot climates, particularly on the west coast of Africa. 

Spontaneous Extrusion of the Lens is of very rare occurrence. In 
a case reported by R. J. Hamilton, an infant of four months was brought 
to him with an apparent rupture of the corneoscleral margin. The mother 
stated that the lens had come out while she turned the child on her knee. 
A week later the night nurse reported that the other lens had been extruded, 
it being found on the pillow while the child was asleep. The child died 
the following day and post-mortem examination showed that the vitreous 
chamber was occupied by a white, opaque membrane which was attached 
posteriorly to the centre of the optic disc, from which it spread out in 
pear-shape and was attached at several points to the chorioid. Tn con¬ 
tracting it had separated the chorioid from the sclera. The contraction 
of this membrane was the vis a iergo which was sufficient to expel the 
lens through what is the weakest part of the eye in early life, viz.: the 
corneoscleral margin. 

Ossification of the Lens has been observed by Panas and others. 

Regeneration of the Lens.—The reproduction of the human lens after 
extraction has never been demonstrated, although Vrolik claimed to have 
seen “a transparent new formation” in the site of a crystalline lens which 
had been removed eleven years previously for cataract. Regeneration 
of the lens in some of the lower animals—as rabbits, dogs, and guinea- 
pigs—does occur. Recently Randolph has published the results of twenty 
experiments made on newts in which he obtained regeneration in six. 
Since “regeneration occurs even when the lens has been removed in cap¬ 
sule,” he concludes that the new lens takes its origin from the iris, thus 
confirming the experiments of Wolff. Great activity of the capsular 
epithelium is often noticed after the extraction of cataract. Randolph 
asks: “May not this be an attempt at regeneration, an attempt which 
is so often successful in creatures lower in the animal series?” 

Injuries of the Lens.—These include rupture of the zonula, disloca¬ 
tion, rupture of the anterior or posterior capsule, and opacity without 
visible lesion (concussion cataract). 

Penetrating injuries without the retention of a foreign body are occa¬ 
sionally seen. Among the agents concerned with the production of such 
injuries are thorns, needles, and knife-blades. The injury may involve 
the zonula, or the peripheral part of the lens, in which case the iris will 
conceal the wound. After perforation of the zonula near its lenticular 
attachment a stellate opacity of the posterior layers of the cortex is likely 
to occur. Often, in these cases, if the eye is not lost by infection, there 
will be complete opacity of the lens. In rare instances the wound in the 
capsule will heal and lenticular opacity will completely disappear. There 


472 


MODERN OPHTHALMOLOGY. 


may be rapid swelling of lens-fibres and increased intra-ocular tension, 
which will necessitate an immediate extraction. In cases of less severity 
the use of atropin will be required. 

Foreign Bodies in the Lens.—Not infrequently foreign bodies, such 
as pieces of iron, steel, or copper, will lodge in the lens. They may be 
visible or hidden, depending upon the depth to which they penetrate, upon 
the amount of lenticular swelling, and upon the time which has elapsed since 
the receipt of the injury. If hidden, they can be localized by means of the 
x-ra} r s. Not infrequently it will be found that the foreign body has either 
passed through the lens into the vitreous, retina, chorioid, sclera, or orbital 
tissues, or has lodged in the ciliary region. 


CHAPTER XIV. 


DISEASES OF THE VITREOUS HUMOR. 

Coloboma of the Vitreous Humor is a rare congenital anomaly which 
appears as a cleft in the under part of the vitreous body, extending in the 
most marked instances from the optic papilla to the ciliary region, while 
in lighter grades it occupies only the anterior or posterior part of the 
vitreous. 

Persistent Hyaloid Artery (Canal of Cloquet).—An unusual anomaly 
is the extra-uterine existence of the hyaloid canal: a lymph-space in the 
axis of the vitreous body. The hyaloid artery, which during fetal life is 
an extension of the central retinal artery, running in the canal of Cloquet, 
generally disappears about the seventh or eighth month of intra-uterine 
life. When persistent, it forms a rare anomaly and runs forward in the 



Fig. 315.—Coloboma of the vitreous humor. (Ecker.) 

vitreous, sometimes reaching the posterior surface of the lens. It may 
be seen floating in the vitreous in one of several forms: as a strand attached 
either to the papilla or lens, as a vitreous vessel carrying blood, as a canal 
without a vessel, or as a cyst-like body. Its presence is not incompatible 
with normal vision, and the anomaly is chiefly of interest as a scientific 
curiosity. In a case recently examined by the author the canal was present 
in both eyes as a funnel-shaped, grayish, floating body. Traces of the 
hyaloid artery are also sometimes seen at the posterior pole of the lens, 
as a speck on the capsule, and at the optic disc as gray, connective-tissue 
tags. According to Mittendorf, these small opacities of the posterior cap¬ 
sule are non-progressive, do not interfere with vision, and are found in 
2.3 per cent, of eyes. 

Inflammation of the Vitreous Humor.—The term hyalitis is applied 
to inflammation of the vitreous body (and not to the hyaloid membrane), 
which presents two forms: one suppurative and the other connected with 
the formation of opacities. Strictly speaking, the changes which are 
about to be described are not distinct diseases, but are simply manifestations 

(473) 


474 


MODERN OPHTHALMOLOGY. 


of pathologic changes in the retina, ciliary body, chorioid, or the optic nerve, 
or are due to trauma. Since the nutrition of the vitreous depends on the 
vessels in the ciliary body and retina, it is apparent that lesions in these 
parts readily affect the vitreous. 

Suppurative Hyalitis (Purulent Inflammation of the Vitreous) is part 

of the condition known as panophthalmitis. It is caused by trauma, par¬ 
ticularly in connection with penetrating wounds with the lodgment of 
a foreign body; and occurs idiopathicallv in connection with metastatic 
chorioiditis following puerperal fever, exanthematous diseases, influenza, and 
low- fevers. Recently it has been shown that idiopathic inflammation of 
the vitreous humor may occur without demonstrable changes in any other 
part of the eye. Suppurative hyalitis may also be caused by microbic 
invasion through old operative wounds, the inflammation appearing from a 
few months to several years after healing. 



Fig. 316.'—Canal of Cloquet, with cyst in the vitreous humor. 

(Koller.) 

(“Transactions of the American Ophthalmological Society,” 1901.) 

Symptoms. —The patient usually gives the history of an antecedent 
iritis or iridocyclitis, and adhesions between the iris and lens-capsule can 
generally be demonstrated. If the cornea and lens are clear, pus can be 
seen in the vitreous as a circumscribed, yellowish, opaque mass, which 
ophthalmoscopically may simulate neuroepithelioma of the retina. To this 
condition the name pseudo-glioma is usually applied. In making a diag¬ 
nosis it will be necessary to consider the history of the case, the age of the 
patient, and the appearance of the mass (see the diagnosis of neuro¬ 
epithelioma of the retina in Chapter XV). Tension in suppurative hya¬ 
litis is usually diminished, but may be increased. Generally the diagnosis 
will not be difficult. Acute suppurative hyalitis producing a yellowish 
mass behind the lens, increased tension, and inflammatory symptoms may 
be mistaken for a neoplasm. The rapid course of the disease and the 
history of the case will usually serve to clear the diagnosis. When scleral 
perforation occurs with a discharge of pus, there will no longer be doubt 
as to the existence of suppurative hyalitis. 


DISEASES OF THE VITREOUS HUMOR. 


475 


Prognosis and Treatment. —The prognosis in suppurative hyalitis 
is serious. The affected eye will be lost and may be a cause of sympa¬ 
thetic ophthalmitis. Shrinking of the globe occurs. Old, tender, cyclitic 
eyes should be removed. During the course of an exhausting disease the 
surgeon may notice vitreous opacities appearing as fine flakes. In such a 
case it is possible that vigorous supportive treatment may check the process 
and save the eye. The possibility of the occurrence of a vitreous compli¬ 
cation in low fevers should not be forgotten by the physician. The treat¬ 
ment of suppurative hyalitis in the present state of our knowledge is 
purely symptomatic. Berry and others have advocated the intra-ocular 
injection of chlorin-water on experimental grounds, but such treatment 
is not to be sanctioned. The intra-ocular use of iodoform may be of value. 

Opacities of the Vitreous Humor.—These are classified as fixed and 
floating, and may be acute or chronic. They may appear as fine, dust¬ 
like particles (particularly in syphilitic retinitis and chorioiditis) or 
may be threads, bands, dots, membranes, or projections. They vary much in 
size, shape, and color. The fixed opacities are generally fastened at two 
or more points. 

Etiology.— Opacities of the vitreous result from many different con¬ 
ditions, among which are the following: Errors of refraction, particularly 
myopia of high degree; inflammation of the retina and uveal tract; 
traumatisms producing hemorrhages from the ciliary region or chorioid; 
depraved conditions of the general system from low fevers or other exhaust¬ 
ing diseases, anemia, loss of sleep, gout, syphilis, menstrual disorders, 
constipation, portal congestion, malaria, the long-continued use of arsenic, 
etc. Large fixed opacities may result from trauma and may simulate 
neoplasms. In many instances opacities of the vitreous are present in 
persons in whom other affections are not demonstrable; this is particu¬ 
larly true of elderly persons. Under the name asteroid hyalitis Benson 
has described a condition in which small, light-colored spheres are found 
in the vitreous. It is probably a congenital condition. 

Symptoms. —The subjective symptoms of vitreous opacities depend 
on the number and size of the opaque spots. The patient sees them as 
black specks floating in the visual field (muses volitantes). They are 
particularly annoying when the patient is looking at a bright surface. 
Visual acuity may or may not be reduced. Reduction of vision, pain, and 
asthenopic symptoms will cause the surgeon to seek errors of refraction, 
associated ocular changes, or diseases of the general system. 

Vitreous opacities can be seen by using a concave retinoscopy mirror 
of twenty-five centimetres’ focus. Whether the spots are fixed or floating 
can be determined by having the patient move his eye while under examina¬ 
tion. After movement the eye is to be held perfectly quiet. Fixed opaci¬ 
ties will remain in situ , while floating ones will be seen to move, and their 
rate of movement gives an indication of the consistency of the vitreous. 
In a vitreous body of normal consistency the spots move slowly; in a fluid 


476 


MODERN OPHTHALMOLOGY. 


vitreous the movement is rapid. Vitreous opacities, if floating, move in a 
direction opposite to the movement of the e}'e, while opacities in the lens 
and cornea move in the same direction as the ocular movement. This is 
because the latter opacities are fixed. By using a -j- 14 or 16 D. lens, by 
direct ophthalmoscopy, fixed vitreous opacities can be examined satis¬ 
factorily. 

Prognosis and Treatment. —The prognosis in vitreous opacities 
depends on the cause. When resulting from syphilis the opacities readily 
clear up under proper treatment. If caused by hemorrhage, the clot 
may or may not be absorbed. In opacities caused by purulent chorioiditis 
the prognosis is grave, the eye ending in phthisis bulbi. Muscse volitantes 
show no opacities to the ophthalmoscope, and are probably caused by 
shadows of the remains of embryonic tissue thrown on to the retina. 
They are exceedingly annoying, and often remain in spite of the correction 
of refraction errors and attention to the general health. They are not 
significant of serious lesions. 

The treatment of opacities of the vitreous includes the removal of 
the cause, the regulation of the habits of the individual, and the exhibition 
of remedies for the purpose of producing absorption. Iodid of potassium, 
the various preparations of mercury, pilocarpin, and saline laxatives are all 
valuable measures. The use of the galvanic current, paracentesis of the 
anterior chamber, and the subconjunctival injection of a 5-per-cent, strength 
salt solution are among the measures which have been advocated. The 
intra-ocular injection of various mercurial salts, iodid of potassium, and 
carbolic acid has been proposed. This method of treatment should be 
condemned, as it is dangerous to the eye. 

Hemorrhage into the Vitreous Humor.—This may occur spontane¬ 
ously from rupture of a diseased vessel or as the direct result of trauma. 
Idiopathic hemorrhage occurs chiefly in chorioiditis, retinitis, high myopia, 
and in elderly persons with atheromatous arteries. It is likely to come on 
after severe physical strain or after the excessive use of stimulants. Among 
the general disorders which are regarded as causes are anemia, leukemia, em¬ 
physema, and syphilis. Hemorrhage into the vitreous humor may be the 
first sign of tuberculosis of the ciliary body. A form of spontaneous hemor¬ 
rhage, coming on repeatedly at intervals, is sometimes seen in young persons, 
particularly in men who are gouty or are the subjects of vascular dis¬ 
turbances, or are habitually constipated. 

Symptoms. —Hemorrhage into the vitreous causes loss of vision, which 
may be only slightly reduced or completely abolished. Generally in such a 
case there will remain ability to count fingers or the retention of perception 
of light at the time of the hemorrhage. At a later period the case may 
show much improvement in vision or total loss of it. In some cases the 
patient can read print in a hesitating manner, certain parts of the field being 
obscured immediately after the hemorrhage. Patients often complain that 
objects appear red (erythropsia). 


DISEASES OF THE VITREOUS HUMOR. 


477 


To the ophthalmoscopist the hemorrhage appears as a dark-brownish 
or black mass with red borders. In some cases there is so much blood in 
the vitreous that no fundus-reflex is obtainable. In these patients oblique 
focal illumination is to be employed. If a thin layer of blood is present 
the fundus seems covered with a bright-red veil. After absorption has 
progressed numerous opacities are found in the vitreous. In some cases 
these eyes end in glaucoma, detachment of the retina, retinitis proliferans, 
and iritis. 

Prognosis in these cases is always serious. The younger the subject 
and the smaller the hemorrhages, the more favorable will be the prospect 
for rapid absorption. Repeated hemorrhages in young persons sometimes 
end in nearly complete restoration of vision. In traumatic hemorrhages 
the prognosis will depend, not only on the amount of blood effused, but also 
on other concomitant lesions. 

Treatment. —In robust persons the eyes should be bandaged. The pa¬ 
tient should be placed in bed, and a vigorous course of purgatives with sub¬ 
cutaneous injections of pilocarpm instituted. The internal administration 
of iodid of potassium is of value. The use of eserin and repeated tapping of 
the anterior chamber have been recommended. In anemic individuals these 
severe measures must be used with caution. After recovery attention should 
be given to the relief of any local or general departure from the normal 
condition. Stimulants, excessive exertion, and late hours should be avoided. 
In hemorrhages occurring in young women about the time of puberty, 
attention should be paid to the uterine functions. 

Fluidity of the Vitreous (Synchysis Corporis Vitrei) occurs as the 
result of chorioiditis or retinitis, and is found in high myopia by reason of 
the fact that in these conditions the nutrition of the vitreous is disturbed. 
Under these circumstances the vitreous body becomes a thin fluid of a straw 
color. In cataract extractions it is sometimes observed that considerable 
watery fluid, in excess of the amount of aqueous, flows out of the wound. In 
such patients the anterior part of the vitreous has become thin. With 
diminished consistency there may be shrinkage of the vitreous. The an¬ 
terior chamber may be increased in depth from a backward movement of the 
lens, and detachment of the retina may be present. According to Griffith, 
in cases of fluidity of the vitreous the ocular tension is more often increased 
than diminished. Tremulousness of the iris is often present in this disease. 
The condition does not admit of successful treatment. 

Synchysis Scintillans (Sparkling Synchysis; Synchysis Etincelant) is 
the term applied to a striking and beautiful appearance due to the pres¬ 
ence of crystals in the vitreous. These usually consist of cholesterin, 
although margarin, tyrosin, and phosphates are sometimes found. Ophthal- 
moscopically the appearance is usually that of innumerable small, moving, 
shining particles which have been likened to a shower of gold, although 
cases have been observed in which the particles appeared as white, glistening, 
round discs, or small, cream-colored bodies. Sparkling synchysis is a senile 


478 


MODERN OPHTHALMOLOGY. 


condition, having been observed only in persons over fifty years of age. As 
a rule, vision is normal. The affection may be unilateral or bilateral, and 
is irremediable. 

Animal Parasites in the Vitreous Humor.—Three kinds of animal para¬ 
sites have been found in the vitreous body. They are the cysticercus cellu- 
losse, which is not rare in North Germany, where raw meat is often an 
article of diet, but is extremely uncommon in France, Austria, England, 
and America; the filaria sanguinis hominis, which has been observed a few 
times; and the hydatid cyst, which is of rare occurrence. 

Cysticercus, which is the scolex of taenia solium, gets into the eye in 
this way: joints of a tenia lodge in the stomach, are digested,.and the eggs 
are set free; or the eggs get into the stomach by contaminated water or 
food. Embryos develop from the eggs, penetrate the walls of the stomach 
by their booklets, and enter the vessels, by which they are transported to 
distant parts. When leaving the vessels they bore into the tissues and grow 
into cysticerci. In the eye the cysticercus generally develops under the 
retina, which it lifts up and perforates, thus getting into the vitreous. 
It may enter the vitreous directly through the vessels of the ciliary body 
(A. Kraemer). If of subretinal origin, its development can be watched 
with the ophthalmoscope. In the vitreous body it looks like a small blad¬ 
der, usually from three to six times the size of the optic disc, and is of a 
bluish-white color. So long as it is alive it often moves actively. Fre¬ 
quently, however, the cysticercus is seen indistinctly by reason of opaque 
membranes, which obscure it, and under such circumstances diagnosis may 
be difficult or impossible. Cysticercus occurs in one eye only, but two or 
more may inhabit the affected organ. In many instances the patient com¬ 
plains only of loss of vision, or the eye is transiently reddened, and there 
may be photophobia. After remaining in this state for a varying period, 
inflammation of the anterior ocular segment will cause the patient to 
consult the surgeon. 

Diagnosis .—If the vitreous is clear, the diagnosis of cysticercus pre¬ 
sents no great difficulty; if purulent hyalitis is present, the diagnosis 
will be impossible. In making a differential diagnosis it will be necessary 
to take into consideration several conditions, among which are: manifest 
canal of Cloquet, persistent hyaloid artery, detachment of the retina, and 
in children neuroepithelioma of the retina. 

Prognosis and Treatment .—Unless the process is checked by removal 
of the parasite, cysticercus sooner or later leads to complete destruction 
of the globe. The treatment is operative; but unfortunately the difficulties 
are such that removal of the parasite with retention of useful vision is pos¬ 
sible in only few cases, while many of the attempts have ended in enuclea¬ 
tion. Of 60 cases tabulated by Wagner, the eyeball was saved in 44, and, 
of these, 21 gave a good cosmetic result. In 4 cases vision equal to the 
counting of fingers was retained, and in 19 cases vision was improved by 
the operation. The method of procedure will readily suggest itself to the 


DISEASES OF THE VITREOUS HUMOR. 


479 


ophthalmic surgeon. This will include section of the cornea, extraction 
of the lens, and seizure of the cysticercus with forceps; or the sclera can 
be opened at the infero-temporal oblique meridian, the vitreous humor 
freely incised, and the parasite delivered by forceps. 

Formation of New Vessels in the Vitreous. —A rare condition is the 
development of new blood-vessels in the vitreous. They are derived from 
the retinal system, generally coming from the optic disc, but have been seen 
springing from the periphery of the retina. After running forward as 
fine, convoluted branches they form loops and return. Most of the cases 
on record occurred in syphilitic subjects, and in several of them there were 


Fig. 317. —Extensive vascular growth in the vitreous humor. (Harlan.) 

(“Transactions of the American Ophthalmological Society,*’ 18S9.) 



hemorrhages into the vitreous. The only case of new vessel-formation in the 
vitreous which the author has seen occurred in a man who attempted suicide, 
but succeeded only in passing the bullet through both orbits. The optic 
nerve on one side was severed close to the globe. In this eye an intense 
papillitis and abundant vitreous hemorrhage was followed by the formation 
of a large opaque mass in the posterior pole and the subsequent development 
of new vessels. In some of the reported cases, under antisyphilitic remedies, 
the exudation has cleared and many of the vessels have disappeared. In a 
case recorded by Ilirschberg a bluish mass of connective tissue was situated 
on the disc, hiding the exit of the vessels, while a vascular web, likened 
to the framework of a fly's wing, extended upward and inward. Hie treat- 






4S0 


MODERN OPHTHALMOLOGY. 


ment of this rare condition consists in the internal administration of mer¬ 
curials and iodids. 

Pseudo-neuroepithelioma (Pseudo-glioma), a localized collection of 
pus in the vitreous which simulates a retinal tumor, will be considered in the 
following chapter. 

Foreign Bodies in the Vitreous. —The vitreous frequently is the seat 
of foreign bodies, which pass through the cornea and lens or through the 
sclera. They are often small metallic substances, pieces of iron or steel, 
guncaps, pieces of glass, stone, shot, etc. They often cause suppurative 
hyalitis even if removed early; if permitted to remain they may produce 
sympathetic ophthalmitis. In some few cases the foreign body can be seen 
with the ophthalmoscope; often, however, it is invisible by reason of hemor¬ 
rhage into the vitreous, and its location can then be determined by the use 
of the Bontgen rays. For the diagnosis and treatment of foreign bodies 
in the vitreous the reader should consult the chapter on the “Sclera” (page 
370). 

Detachment of the Vitreous, with sequent detachment of the retina, 
is mentioned as the result of trauma, intra-ocular tumors, old inflammatory 
processes in- the vitreous, chorioiditis, hemorrhages, cyclitis, and posterior 
staphyloma. The condition is not diagnosticable until after enucleation. 
Some writers on ophthalmology profess to have foretold the condition in - 
highly myopic eyes by reason of sudden diminution of vision, concentric con¬ 
traction of the field, with the presence of a sharply defined, crescentic, 
grayish zone around the papilla, within which the retinal vessels appear 
bent. That detachment of the vitreous humor is a frequent condition is 
shown by the statistics of Jennings Milles, who found it in 43 of 345 excised 
eyes. 

Retinitis Proliferans, which is considered in the following chapter, 
produces bluish-white masses adherent to the inner surface of the retina, 
where they often conceal the optic disc. From them numerous interlacing 
strands, branching in an indiscriminate manner, pass into the vitreous. 


CHAPTER XV. 


DISEASES OF THE RETINA. 

The retina, the intra-ocular expansion of the optic nerve, is liable 
to congenital anomalies, tumors, parasites, functional diseases, changes due 
to circulatory disturbances, inflammations, detachments, and injuries. 


CONGENITAL ANOMALIES. 

These include coloboma, opaque nerve-fibres, some punctate conditions 
of the fundus, variations in pigmentation, and peculiarities of the blood¬ 
vessels. Coloboma of the retina has been considered in Chapter XII with 
coloboma of the chorioid (page 411). A congenital anomaly which the 
inexperienced observer may mistake for neuroretinitis is the presence of 
opaque nerve-fibres in the retina. This condition is due to the fact that the 
medullary sheath of the axis-cylinders is continued into the retina and ap¬ 
pears as bright, white, striated patches found usually above or below the 
optic papilla and presenting a frayed or flame-like extremity (Fig. 2, 
Plate IV). Exceptionally they are not contiguous to the disc, in which 
event they may be mistaken for fatty deposits. Sometimes the retinal ves¬ 
sels are partly covered by the opaque fibres. The existence of opaque nerve- 
fibres does not influence vision. 

Punctate Conditions of the Fundus, some of which are congenital and 
others acquired, will all be considered later on in this chapter. Variations 
in retinal pigmentation are numerous. Isolated dots are not uncommon; 
groups of pigment-dots of a brown or black color, the dots being angular or 
rounded in shape, and occupying an area between some of the primary 
divisions of the vessels, are less frequently seen. They are distinguishable 
from pathologic dots by the fact that the remaining portion of the fundus 
is normal and each dot is isolated and clearly defined. Vision in such 
cases is normal. Larger pigment-areas of oval outline have been occa¬ 
sionally observed -and have been likened to moles on the skin. Eetinitis 
pigmentosa and neuroepithelioma (glioma) of the retina, which are occa¬ 
sionally present at birth, do not differ from the same conditions found later 
in life. Insufficient pigment is the condition noted in blondes and albinos. 
In the former the chorioidal vessels become prominent, while in the latter 
the observer finds a network of red vessels spread over a yellowish or whitish 
field. Variations in the macular region have been described in Chapter II 
(Plate V). Variations in the blood-vessels have also been mentioned in 
Chapter II (page 59). Extreme tortuosity is sometimes associated with 

(481) 


31 


482 


MODERN OPHTHALMOLOGY. 


undue prominence of the optic discs, and may simulate papillitis. The 
vision in such patients is either normal without, or becomes normal with, 
the proper glasses. These patients are generally hypermetropic. The con¬ 
dition is discussed in the succeeding chapter under the term “Spurious Optic 
Neuritis.” 

TUMORS OF THE RETINA. 

The tumors of the retina are cyst and neuroepithelioma (glioma). 
Retinal cysts, which are only rarely discovered before enucleation, are 
found in the detached retinas of degenerated eyes, and are due to circu¬ 
latory disturbances. Liquid transuded from the retinal vessels forms cysts, 
which may spread for some distance in the membrane. They are of interest 
chiefly to the pathologist. It is only when the cysts are located far for¬ 
ward, and the lens remains clear, that they can be seen. They may be mis¬ 
taken for tumors of the ciliary body, but the lowered tension and the history 
of the case will invalidate such a diagnosis. 

Neuroepithelioma (Glioma) of the Retina.—This disease, formerly 
called glioma of the retina, fungus hsematodes oculi, or sarcoma of the 
retina, in the light of modem pathology is regarded as epithelial in origin. 
The name neuroepithelioma was first applied to a retinal tumor by Flexner. 
Wintersteiner, after exhaustive microscopic study of these tumors, con¬ 
cluded that they arise from the neuroepithelial layer of the retina, and 
should be named neuroepitheliomata. According to its location and the 
direction of growth, the following varieties are distinguished. They exist 
only in the early stages:— 

1. Several nodes the size of a pinhead appear in the retina; they 
grow only slightly toward the vitreous, but spread in the subretinal space. 
By confluence they form a tuberose deposit on the outer surface of the 
detached retina: neuroepithelioma exophytum or tuberosum. 

2. The detached retina is thickened in its entire extent or in spots; the 
deposits remain comparatively thin and level; later by proliferation the 
surface becomes uneven and protuberant: neuroepithelioma >diffusum or 
planum. 

3. The new growth increases only in the direction of the vitreous; the 
retina remains attached to the chorioid; the mass spreads upon the inner 
surface of the retina, to which it is united not closely, but by processes; the 
vitreous surface of the growth is finely lobulated, cauliflower-like, or 
nodular: neuroepithelioma endophyium. 

Pathology. —Unlike intra-ocular sarcoma, neuroepithelioma is never 
pigmented. The tumor grows from the two granular layers of the retina, 
but chiefly from the inner one. The mass is composed of small cells in a 
soft basement-substance. The cells consist of nuclei surrounded by proto¬ 
plasm in which minute processes are often found. Some are glia-cells, 
others are ganglion-cells. The cells are especially numerous along the 
larger vessels, and this arrangement gives rise to the tubular appearance 


DISEASES OF THE RETINA. 


483 


seen in the accompanying illustration (Fig. 319). Many specimens pre¬ 
sent lo'ng cylindric cells from the neuroepithelium of the retina. These 
form groups inclosing a free cavity, into which the extremities of the cells 
project. The retina becomes irregularly thickened, folded, and detached. 



Fig. 318.—Rosette of neuroepithelial cells with short protoplasmic processes. 

(WlNTERSTEINER.) . 

A hyalin concretion is shawn in the illustration. 

Small free nodules involve both the chorioid and the vitreous humor. 
Degeneration of the intercellular substance occurs very early. 

Etiology. —The cause of neuroepithelioma of the retina is unknown. 
It is a disease of childhood, no true case having been found after the six¬ 
teenth year. Cases heretofore reported of greater age have been found 



Fig. 319.—Tubulose structure of neuroepithelioma of the retina. 

(WlNTERSTEINER.) 

The blood-vessels are surrounded by layers of cells ; the intercellular substance is necrotic, 
and several calcareous concretions (stained black) appear. 

to be either sarcomas of the chorioid or pseudo-neuroepitheliomata. Of 
467 true cases, 314 occurred during the first three years, 62 in the fourth, 
and 29 in the fifth year. The disease surely is congenital in 10 per cent, 
of the cases, and possibly in the majority. Sex is without influence in this 
disease. In 25 per cent, of the cases both eyes are affected. The second 



484 


MODERN OPHTHALMOLOGY. 


eye becomes involved independently, there being no extension of the dis¬ 
ease via the chiasma. The disease often appears in several children of the 
same family. Lerche saw four cases among seven brothers and sisters and 
Wilson met with a family of eight, all of whom had neuroepithelioma of 
the retina. 

Symptoms. —Usually the first symptom is a peculiar reflex from the 
interior of the eye, which, from its resemblance to a cat’s eye shining in 
the dark, was named by Beer and the older authors “amaurotic cat’s eye.” 
The parents may note that the child does not see with the affected eye. 
In this, the first stage, there is no pain or redness, the media are clear, 
the pupil is somewhat dilated, and the child’s health is unaffected. 
Ophthalmoscopic examination shows a whitish, yellowish, or reddish-yellow 
mass in the fundus. The growth is covered with a plexiform network of 
vessels and has a smooth or nodulated surface. In this stage the growth 
increases slowly, and months may pass before the mass fills the globe, thus 
completing the second stage. 



Fig. 320. —Neuroepithelioma of the retina. (Wintersteiner.) 

Three separate tumors are present, the smallest being at the posterior pole of the lens. 

In the third stage there is increased tension. The child becomes fret¬ 
ful, emaciated, and cachectic. The neoplasm enmeshes all the tissues of 
the globe, and finally breaks out at the corneoscleral junction in front or 
at the optic-nerve entrance behind. Once out of the globe it grows rapidly, 
forming a large, ulcerated mass, which bleeds at the slightest touch. This 
condition was named by the older authors “fungus haematodes oculi.” 
Now other organs are involved by contiguity or by metastasis. The optic 
nerve furnishes a road by which the growth rapidly travels brainward. 
Metastases may take place in the brain, cranial bones, lymphatic glands, 
parotid gland, spinal cord, liver, lungs, ovaries, kidneys, submaxillary gland, 
or spleen. The patient dies of exhaustion. 

Diagnosis. —If the ophthalmoscope shows a whitish tumor, with 
retinal vessels coursing over it, and the tension is increased, the case prob¬ 
ably is one of neuroepithelioma. An error in diagnosis is possible in two 
directions: a tumor may be present and be overlooked, or a diagnosis of 
neuroepithelioma may be made, the eyeball may be removed, and the micro- 


DISEASES OF THE RETINA. 


485 


scopic examination show incorrectness of the diagnosis. Hirschberg’s dic¬ 
tum that a diagnosis between true and false retinal tumors is always possible 
has been found erroneous. The most careful diagnosticians have often been 
in error. Of twenty-four eyes removed at Moorfield’s Hospital between 
1888 and 1893 for “glioma,” seven were “pseudo” growths. Retinal detach¬ 
ment and suppurative processes in the vitreous humor cause frequent mis¬ 
takes. Always the history of the case is important. The parents should be 
questioned as to trauma, meningitis, typhoid fever, grippe, and other infec¬ 
tious diseases, since these are followed by diseases of the vitreous humor. If 
the tension is greatly increased, the case is probably one of neuroepithelioma; 
if the tension is decidedly reduced, it is not neuroepithelioma. Between 
these extremes are cases in which tension is normal or changes from time 
to time. The presence or absence of blood-vessels on the growth is impor- 



Fig. 321. —Neuroepithelioma of the retina. (Author.) 

tant; if present, the case is probably neuroepithelioma; if absent, the tumor 
is usually due to an exudative chorioiditis. Unfortunately, however, there 
are neuroepitheliomata which are not vascular; and, on the other hand, exu¬ 
dation into the vitreous humor sometimes becomes vascularized. The 
“amaurotic eye” reflex is valueless in differential diagnosis. The conditions 
often mistaken for neuroepithelioma, according to Wintersteiner are:— 

1. Simple Detachment of the Retina .—This is comparatively rare in 
childhood. Although a tumor shows a more yellowish or reddish color than 
a detachment, which is of a bluish tint as a rule, yet it must be remembered 
that, with a small tumor and a large detachment of the retina, the folds 
of the latter can completely conceal a neoplasm; and although the newly 
formed vessels of a tumor generally present a course and ramifications 
different from those of the retinal vessels, yet, on the other hand, there are 
cases which show almost no vessels. Although, as a rule, a retina which 


486 


MODERN OPHTHALMOLOGY. 


is lifted up by serous effusion vibrates and floats when the eye is moved, 
while a retina detached by a tumor remains at rest, yet exceptions occur. 
The statement that in simple retinal detachment the tension is reduced and 
in intra-ocular tumor it is increased must be accepted with allowances, for 
in the first stage of neuroepithelioma tension is normal, and, on the other 
hand, in serous detachment it is often increased. 

2. Leucosarcoma of the Chorioid .—This is a comparatively rare dis¬ 

ease in childhood. Of 259 sarcomas of the uveal tract, Fuchs found 6 
leucosarcomas in children under twelve years of age. In these cases the 
symptoms of intra-ocular tumor are added to those of retinal detachment. 
The diagnosis is particularly difficult if the media are opaque or if the 
chorioidal tumor perforates the globe posteriorly without causing retinal 
detachment. , 

3. Tubercles in the Chorioid .—Here the history of the case is impor¬ 
tant. Miliary tubercles of the chorioid are usually found near the optic- 
nerve entrance in the macular region. They appear as whitish-yellow 
masses or nodules in the stroma of the chorioid, varying in size from one- 
eighth the diameter of the optic disc to the size of the disc itself. By 
confluence they sometimes form large masses. A rare condition is solitary 
tubercle, which appears as a nodule and resembles a beginning neuro¬ 
epithelioma. Diagnosis is particularly difficult in cases where the vitreous 
chamber is filled with granulation tissue, and in consequence of secondary 
glaucoma scleral ectasia appears. The diagnostic difficulties are shown 
by two cases reported by Jung: In the first neuroepithelioma was diagnos¬ 
ticated and tuberculosis was found; the second was regarded as tubercular 
and a tumor was found. 

J. Chronic Inflammatory Processes in the Chorioid and Ciliary Body. 
—These are the conditions most often causing error. They show retinal 
detachment and the presence of a fibrinous vitreous exudate, which later 
becomes organized. The chief points in differential diagnosis are these: 

(a) In exudative chorioiditis the color of the vitreous mass is a metallic, 
brass-like yellow, while in the retinal neoplasm whitish, yellowish, reddish, 
and green tints are seen; yet even here the metallic lustre may be observed. 

(b) Many observers state that the exudate is non-vascular, while a retinal 
tumor possesses vessels. Others equally competent report cases of true 
neoplasm in which vessels were never visible to ophthalmoscopic examina¬ 
tion; and, on the other hand, an exudate into the vitreous often undergoes 
organization, (c) The surface of a tumor is knobbed; that of an exudate is 
smooth or ragged. A tumor growing into the vitreous may have a smooth 
surface if it presses against the lens, while an exudate may become shrunken 
and conglobate. In such cases it may be impossible to make a diagnosis 
macroscopically even after enucleation. A tumor with a smooth surface 
may be a neuroepithelioma growing chiefly into the retina, (d) Early 
in neuroepithelioma of the retina the tension is normal; later it is in¬ 
creased. In vitreous exudation it is usually diminished. Yet there are 


DISEASES OE THE RETINA. 


487 


exceptions. The author has seen one case of pseudo-glioma with increased 
tension, (e) Posterior synechise and other evidences of iridal inflammation 
are not reliable, since they may be present or absent in each condition. 

5. Acute Suppurative Hyalitis producing a yellow mass behind the 
lens, inflammatory symptoms, and increased tension can be mistaken for 
a neoplasm. The rapid course of the disease; the presence of hypopyon, 
scleral perforation, and the discharge of pus will serve to clear the diag¬ 
nosis. 

6. Cysticercus in the Vitreous can scarcely be a cause of mistaken diag¬ 
nosis in this country, since it is an extremely rare disease in America, 
although common in Germany. It appears as a bluish-white mass in the 
vitreous, without vessels, with normal tension and blindness. 

7. Congenital Abnormalities. —In some instances eyes have been 
enucleated for neoplasm and examination showed persistent vascularity 
of the lens-capsule, and a hyaloid artery with posterior polar cataract. 



Fig. 322.— Pseudo neuroepithelioma of the retina. (Author.) 

The patient was a boy, aged five years, whose right eye had presented a grayish pupillary 
reflex for one year. The ophthalmoscope showed the presence of a whitish mass in the vitreous 
chamber. No vessels could be seen on the growth or elsewhere within the eye. Vision was lost; 
the tension was at times normal, at other times increased. There was no redness of the conjunctiva 
and no pain. The diagnosis was not made positively until after the eyeball had been enucleated 
and sections made. The growth is a connective-tissue mass, with numerous round cells, the result 
of inflammatory action. There was no history of trauma in this case. The specimen shows com¬ 
plete detachment of the retina. The anterior chamber is much shallowed. 

S. Retinitis Circinata, when occurring in children, may be mistaken 
for neuroepithelioma of the retina (see “Retinitis Circinata”). 

9. Detachment of the Retina with Dropsical Degeneration of the Visual 
Cells (rods and cones), according to de Schweinitz and Shumway, may 
exactly resemble neuroepithelioma. 

Prognosis. —This is always serious, but depends upon the stage of the 
disease. Without treatment neuroepithelioma of the retina always causes 
death. Early operations are followed by 13 per cent, of recoveries. If the 
growth has penetrated the eyeball, and particularly if perforation occurs 
posteriorly, death is almost sure; but operation will probably prolong life. 
Operation for recurrence is useless. It is said that if the disease does not 
return within four years the patient will be exempt. 



488 


MODERN OPHTHALMOLOGY. 


Treatment. —The treatment of neuroepithelioma retinas should be 
early and heroic. Any suspicious growth within the eye of a child calls 
for immediate enucleation and removal of the orbital part of the optic 
nerve as far back as possible. The eye should then be submitted to a 
competent pathologist for microscopic diagnosis. If found to be true 
neuroepithelioma retinae, the orbital contents should be removed. This 
leaves a great deformit} r , but increases the chance of saving life. In cases 
where the neoplasm has already pierced the globe exenteration of the orbit 
should be done immediately, unless the disease has progressed so far that 
the patient cannot recover from the depression of the anesthetic and opera¬ 
tion. If the neoplasm has invaded the cavities adjacent to the orbit, 
operation is contra-indicated. In a case with involvement of both eyes the 
same principles of treatment should apply. 

If an eye containing a tumor still possesses some vision, it will be 
best not to temporize. It is wiser to sacrifice a dozen half-blind eyes con¬ 
taining pseudo-neuroepitheliomata than to operate on one true case too late. 
In all cases of intra-ocular growth the general practitioner should seek 
counsel of an ophthalmologist, who, in turn, should have the advice of his 
confreres. 


PARASITES. 

Subretinal Cysticercus.—This parasite, whose frequency depends on 
the geographic distribution of taenia solium, is rarely observed in Great 
Britain, Russia, France, and Holland. It is occasionally seen in Germany, 
Italy, and Hungary. Few eases of this disease have been reported in the 
United States. The retina and chorioid are favorite sites for cysticercus. 
Thus, of 29 cases of intra-ocular cysticercus in which the eye was sub¬ 
jected to anatomic examination, 13 were subretinal (Kraemer). When 
located centrally a cysticercus causes marked loss of vision. The eye 
usually presents normal or subnormal, rarely increased, tension. To the 
ophthalmoscope the larva appears as a bluish or whitish, bladder-like mass 
with an orange border. The location of the head is indicated by a white 
spot and in some cases its movement can be observed. After a time the 
head breaks through the retina and enters the vitreous humor, which be¬ 
comes opaque. At first the vitreous opacities are transparent, movable, 
and of a bluish-white color. Later the whole vitreous becomes opaque, a 
chronic iridochorioiditis ensues, and the eye ends in atrophia bulbi. The 
parasite may be found at any age. The life of a cysticercus is said to be 
from three months to two years. The diagnosis of subretinal cysticercus 
is not difficult as long as the media are clear. Cysticercus occurring in a 
child may be mistaken for neuroepithelioma of the retina; in the adult 
it may simulate sarcoma of the chorioid. The prognosis is unfavorable. 
An early operation may result in the preservation of the globe. A few 
cases have occurred in which the patient after operation retained useful 
vision. 


PLATE XV, 

Diseases of the Retina. 


Fig. 1.— 1 Th.3 Fundus In a CasB nf Pernicious Anemia, (Oliver.) 


Fig. 2.—Leucccytliemia Rstlnltls. (Oliver.) 





•XO 'M i of 

Q-f i < t'*: ■ 


* 

,WX ET^ J-I 

; - \,t V 

.Ba.iiB.ri. a.dr in esiiacfttCr 

■ i . • ,> r ;ii: ret ire should be 

. -tiitr the eye of a child calls 
orbit a* part of the optic 
*. iid then be submitted to a 

1 !i ms„; H found to be true 

nts should b< removed. This 
j i chance of s?.' ing life. In cases • 

.■ i In u. - '.<! ■ . v» ti|- globe eyemenvticn of the «>rb t 

1 r-e has ;*rogressed sc 
e n if i. .• t- esthetic and opera- 

( ; pi ;:.i t}>( .'aviiies ad, .cent. to die orbit 

:.!■ ,, v h „ v ith invoUr ut of both eyes the 
(..arr iilj j arjoiaiotst to asst) k nx bxsturrt bjIT —.X .grTC 

3> ;V to sacrii'ce a doaon halt-blind eyes con- 
•.in !/» per ;topi! on* true cs e too late. 

!• O'.' m ei i 'ic v li' toner should seek 

an ojdi'i i.-;ibu iog.-u. vi >. iu turn, shoaid have the advice of his 


PAR kSITRS. 




Subt;” final OysbkcccttB.---This parasite, whose frequency do pends on 
: -utvn -oi :u sriiani, ;• " rely observed i'n G real 
h’ s: -,r, , and jlo.'oiTt is oce;.:knally seen in Gmua iy, 

1 H l< v eu^ »•. disease hir u< v. r< . 'Or-ed on the 

. • oa ; i i i-u d are fav-doi tor cstb: reus. 




■ • ' utr •’ i u r • vieef'm in m « the eye wo- sub- 

i i«n. atioo, 13 were #ubre ;r: - 1 ■> raenmr). 'non 

r bnoi >i; i :are.l in. ’<.: •<], tension. To the • 

•« * Jrfc -a ilu;-h or wbi blaclder-liko mass 

l'd IjY ;• ’ '. h ■*> 

.:•> • s: >.-fuent can be ol> -rv.After a time the 


• \ enters the vi-tr* »imor, ■which be- 

fc oj.uuht • are ♦. re n r :nt, movabl , 

OravilC). .ziltaasH S .fei'T' ' Op.i >V!«, Jt 

V ■ ‘! . 1 < 0 ;> i • i.-rCH§ 

. 






PLATE 15 







DISEASES OF THE RETINA. 


489 


Subretinal Echinococcus.—One case of this disease, that reported by 
Gescheidt in 1855, is recorded in ophthalmic literature. 


RETINAL CHANGES FROM CIRCULATORY DISTURBANCES. 

Anemia of the Retina.—Anemia of the retina is simply a local ex¬ 
pression of general anemia, and may be exceedingly difficult of diagnosis. 
In fact, in the absence of a proper examination of the blood, diagnosis 
with the ophthalmoscope may be impossible. In some cases, however, the 
fundus changes are so marked as to be considered almost pathognomonic. 
Thus, in chlorosis, pernicious anemia, and leucocythemia the fundus often 
shows marked changes. The whole fundus is paler than under normal 
conditions; the optic-nerve head is lustreless and grayish, and neuro¬ 
retinitis is common. There is a greater tendency to inflammation of the 
nerve-head and retina in chlorosis than in pernicious anemia, while the 
tendency to retinal hemorrhage is less (Stephen Mackenzie). Posey states 
that in initial anemia from loss of quantity of blood there are seldom 
ocular changes unless some other factor than loss of blood exists. In cases 
of chlorosis and pernicious anemia observed by Oliver there were marked 
changes: the optic disc was of a yellowish-white color, with hazy and in 
places indiscernible edges; the fibre-layer of the retina was opaque, thick¬ 
ened, and striated; the vessels were pallid and showed opacification of 
their lymph-sheaths and pronounced neuroretinitis was present (Fig. 1, 
Plate XV). Visual acuity was reduced and the fields of vision were 
contracted. Coetaneous blood-examinations showed a great diminution 
of red blood-corpuscles and hemoglobin. 

Ischemia of the Retina.—The term' ischemia of the retina indicates 
that the cause of the condition rests in or near the eyeball itself. Thus, 
ischemia follows plugging of the arteria centralis retinas. It also has been 
observed in spasm of the retinal arteries (in quinin-blindness). 

Ischemia of the retina may be general or partial. In embolism of the 
central artery, where the plug is located in the main trunk, the whole fundus 
is white and bloodless except such portions as are supplied by a cilioretinal 
vessel. An example of partial ischemia is found in case the embolus suc¬ 
cessfully traverses the central vessel and lodges in one of its branches. 

The diagnosis between anemia and ischemia of the retina can be 
determined by taking into consideration the general condition of the patient 
and the ophthalmoscopic appearances (see the preceding section and “Em¬ 
bolism of the Central Retinal Artery”). 

Hyperemia of the Retina.—Retinal hyperemia, existing apart from 
demonstrable pathologic lesions, such as hemorrhage and exudation, is of 
rare occurrence, and is diagnosticated with difficulty. Hyperemia of the 
larger retinal vessels is indicated by increased tortuosity, which is to be 
expected when an elastic tube is overdistended. Unless the patient has 
been previously examined, the diagnosis will be in doubt, since what may 


490 


MODERN OPHTHALMOLOGY. 


appear to be undue tortuosity may be simply a congenital condition. The 
calibre of the retinal vessels varies much under normal conditions. When, 
however, congestion of the larger vessels is accompanied by capillary hyper¬ 
emia, there will be a change in the color of the whole fundus and the optic 
nerve will be redder than normal. Hyperemia of the retina is divisible 
into active and passive forms. 

Active Retinal Hyperemia is found in connection with inflamma¬ 
tions of the uveal tract, and as a functional affection due to excessive use of 
the eyes in near work under unfavorable conditions as regards illumination, 
or under abnormal states of refraction or of muscle-balance. It is also 
found among persons exposed to excessive light and heat, as puddlers. The 
symptoms of active retinal hyperemia include photophobia and asthenopia. 
The diagnosis must rest on the results of an ophthalmoscopic examination, 
on the subjective symptoms, and on the history of the case. Hyperemia of 
the retina should not be confounded with the diffuse haziness which is due to 
fine vitreous opacities, or with the apparent distortion of vessels which is 
seen in astigmatic eyes. The treatment will consist in the removal of the 
cause, the proper correction of errors of refraction, and removal from 
unhygienic surroundings. 

Passive Retinal Hyperemia is found wherever the egress of blood 
from the eyes is interfered with, as in glaucoma, brain-tumors, and other 
intracranial diseases producing “choked disc.” Stasis hyperemia is found 
in mitral disease, convulsions, tetanus, and in tumors of the neck inter¬ 
fering with the return of blood. The symptoms are similar to those found 
in active hyperemia. The diagnosis is made by attention to the ophthal¬ 
moscopic findings, the results of a general physical examination, etc. The 
treatment will comprise the removal of the cause, when possible, and the 
correction of errors of refraction, etc. 

Retinal Vasculitis and Perivasculitis (Sclerosis of the Retinal Ves¬ 
sels). —These terms are applied to inflammation of the vessel-walls or of 
the perivascular sheaths. The condition is shown by the appearance of 
white lines along the vessels. Normally the vessel-walls cannot be seen. 

Pathology. —Endarteritis productiva (arteriosclerosis) begins in a 
thickening of the intima; if the process progresses, the condition known 
as endarteritis obliterans develops and the lumen of the artery is much 
reduced. The process is an inflammatory one, and leads to fatty degenera¬ 
tion and calcareous change in the intima. A granulating inflammatory 
process follows in the adventitia with a new growth of connective tissue. 
Calcification follows which may be en plaque or in spots. Macroscopically 
the first evidences of a beginning endarteritis are roughening of the intima 
and yellowish discoloration. Perivasculitis is a similar process which be¬ 
gins in the adventitia. 

Symptoms. —Sclerosis of the retinal vessels usually is attended by 
reduction in visual acuity. Hertel, however, has found arteriosclerosis in 
eyes possessing good vision. In such cases the findings of the ophthalmo- 


DISEASES OF THE RETINA. 


491 


scope will be of much value in the general prognosis as to the duration of 
life of the individual, since arteriosclerosis of the retinal vessels indicates 
serious lesions located elsewhere, particularly in the brain. In some cases 
evidences of vascular disease are presented to the ophthalmoscope when 
physical examination of the heart and of the arteries of the extremities 
fails to reveal lesions. 

In sclerosis of the vessel-walls the ophthalmoscopist finds the vessels 
transparent, the blood-column reduced in diameter, the light-streak wid¬ 
ened, and an interruption in the continuity of the vein at the point where 
it is crossed by an artery. In perivasculitis white lines appear along the 
course of the vessels, and in exceptional instances the vessels appear as 
branching white streaks. 



Fig. 323.—Perivasculitis of the retinal vessels. (Harlan.) 
An area of chorioidal atrophy is seen at the macular region. 


Etiology. —The vascular changes mentioned, while incident to old age, 
are also found in middle-aged and even in young subjects who are syphi¬ 
litic, gouty, or rheumatic. In some cases trauma is a factor. In nephritis 
the retinal vessels are often diseased (see “Albuminuric Ketinitis”). 

Prognosis. —The prognosis in sclerosis or perivasculitis of the retinal 
vessels is unfavorable, there being no known means of effecting a restitu¬ 
tion to the normal. Vision may long remain normal, or it may be sud¬ 
denly reduced or abolished by rupture of a diseased vessel. The finding 
of changes in the intra-ocular vessels is of value in general prognosis, since 
the general arterial tree is often involved in the same pathologic process. 
In cases where the general medical examination fails to reveal cardiac, 
vascular, or renal disease, the ophthalmoscopic findings may be of great 
moment. An examination for life-insurance cannot be considered com¬ 
plete without an ophthalmoscopic examination. 



492 


MODERN OPHTHALMOLOGY. 


Treatment. —This must be based upon general and broad lines, and 
includes the avoidance of excesses, the abandonment of injurious habits, 
the regulation of 'the diet, exercise, etc. 

Aneurism of the Retinal Vessels.-—Different forms of aneurism of 
the retinal vessels have been described as ophthalmic rarities. Magnus 
and Fuchs met with arterio-venous aneurisms produced by trauma, and the 
same condition has been observed as a congenital disease. Fusiform and 
sacculated forms have also been observed; but the commonest condition is 
the presence of numerous miliary aneurisms occurring in arteriosclerosis. 
Trauma, arteriosclerosis, and syphilis are etiologic factors. Since the 
retinal arteries are terminal vessels and a collateral circulation is prac¬ 
tically impossible, it follows that rupture of retinal aneurisms is likely to 
occur, and probably this is the explanation of some cases of retinal hemor¬ 
rhage. The diagnosis of retinal aneurism can be made with the ophthal- 



Fig. 324.—Arterio-venous aneurism of the retina. (Fuchs.) 

moscope. Varicosities in the veins may be mistaken for aneurisms by the 
inexperienced examiner. Occurring idiopathically, retinal aneurism must 
be regarded as significant of vascular changes in other parts of the body, par¬ 
ticularly in the brain. The condition does not admit of treatment. 

Apoplexy of the Retina (Hemorrhages in the Retina).—The differ¬ 
entiation between retinal apoplexy and hemorrhagic retinitis rests on the 
presence of signs of inflammation. A hemorrhage occurring in an eye 
whose retina otherwise appears normal is known as retinal apoplexy; if 
signs of inflammation of the retina are present, the condition is called 
hemorrhagic retinitis. 

Symptoms. —When the hemorrhages involve the macula there is great 
reduction in acuity of vision. Often, however, the macula is' free, the 
hemorrhages being numerous and situated peripherally, in which case cen¬ 
tral vision will be normal. Scotomata due to such lesions will often remain 
unnoticed by the patient. Ophthalmoscopically apoplexy of the retina pre- 






DISEASES OF THE RETINA. 


493 


sents red or black spots, which may vary in size, shape, and number. They 
contrast strongly with the bright-red fundus. They may involve any of the 
retinal layers. When occurring in the nerve-fibre layer they present striate 
or flame-like shapes. Hemorrhages into the deeper retinal layers or between 
the retina and chorioid are rounded or irregular in shape. 

Etiology. —Apoplexy of the retina, while more common among adults 
of advanced age, is not infrequent in both sexes about the age of puberty. 
The middle-aged and elderly subjects present lesions of the heart or arteries 
or changes in the composition of the blood. Some of the young subjects 
are anemic, while others show no departure from the normal. Sudden 
reduction of intra-ocular tension, such as follows an iridectomy made for 
glaucoma, sometimes causes retinal apoplexy. Some poisons—among which 
are serpent virus, phosphorus, and potassium chlorate—may cause the 
affection. Among the constitutional conditions productive of retinal apo¬ 
plexy are (according to Dimmer) septicemia, pyemia, anemia, ulcerative 
endocarditis, leucocythemia, menorrhagia, liematemesis, hemophilia, gout, 
purpura, diabetes, malaria, scurvy; certain renal, hepatic, and splenic dis¬ 
eases; cardiac hypertrophy with valvular stenosis, atheroma of the vessels, 
thrombosis of the central retinal'vein, and embolism of the central artery; 
suffocation, compression of the carotid, and hemorrhages in the newborn. 
Eetinal apoplexy sometimes follows large cutaneous burns. It has been 
observed in cases of fracture of the skull. 

Pathology. —Hemorrhage into the retina sometimes is due to dia- 
pedesis of blood-corpuscles; in the majority of cases, however, actual rup¬ 
ture of an artery or a vein occurs as a result of pre-existing perivasculitis 
or arteriosclerosis. 

Diagnosis. —This will present no difficulties to the surgeon who is 
familiar with the use of the ophthalmoscope. 

Prognosis. —While in some cases, particularly in young subjects, 
retinal apoplexy is followed by complete absorption of the blood and 
restoration of vision without scotomata, the disease in many instances is a 
serious affection. In many cases the apoplexy recurs from time to time. 
There is increase of intra-ocular tension, and the condition is then known as 
hemorrhagic glaucoma: a most serious disease (see Chapter XVII). In a 
period of weeks or months the retinal hemorrhages may undergo absorption, 
leaving chorioidal and retinal changes, which may be limited to small 
areas or may involve the entire retina. If the hemorrhage breaks into the 
vitreous humor, it may leave permanent opacities and lead to proliferating 
retinitis. Hemorrhages into the retina in elderly persons often precede 
cerebral hemorrhage. 

Treatment. —Eetinal apoplexy calls for attention to the patient’s 
general health, and, when possible, removal of the cause. Stimulants 
should be avoided. Eest, and the use of cholagogues and purgatives will 
be of value. Local bloodletting from the temple is said to be helpful. 
Hypodermic injections of pilocarpin and the internal use of iodid of potas- 



494 


MODERN OPHTHALMOLOGY. 


sium or bichlorid of mercury may be employed to stimulate absorption. In 
elderly persons a solution of eserin may be dropped into the eye twice a 
day. 

Subhyaloid Hemorrhage (Effusion of Blood between the Retina and 
Vitreous Body).—The effusion of blood between the retina and vitreous 
humor is of rare occurrence. Hotz. of Chicago, writing in 1893, said he had 
observed only three cases in twenty years' practice. The disease appears 
suddenly and without premonitory symptoms in an eye supposed to be 
normal; vision is reduced to perception of light, which looks reddish or 
brown. The cornea and lens are found to be clear. Ophthalmoscopic ex¬ 
amination shows the presence of a round, oval, or pyriform effusion of blood 
situated usually in the macular region and rarely reaching to the temporal 
border of the disc. Haab has seen cases in which the blood covered part of 
the optic disc. The lower portion of the effusion often presents a darker 
color. Retinal vessels in the path of the hemorrhage are hidden by it. 

Etiology.—S uppression of the menses and cardiac and vascular lesions 



have been found in some of the cases, while in no small percentage not any 
departure from the normal could be detected. 

Diagnosis.— The diagnosis of subhyaloid hemorrhage should not be 
difficult. A subretinal effusion of blood would not conceal the retinal ves¬ 
sels. which would rise over and pass in front of the effusion, and in sub- 
retinal effusion the patient would not complain of red vision. 

Prognosis.- —The prognosis of subhyaloid hemorrhage is favorable, 
vision being entirely restored with the absorption of the clot, which occurs 
in four or five weeks. This favorable termination may be confidently 
expected except in the rare cases in which the hemorrhage is of sufficient 
size to break into the vitreous body. 

Treatment. —The general condition of the patient should be investi¬ 
gated and suitable remedies should be prescribed for any departure from the 
normal. As regards the local affection, the avoidance of stimulants and 
excitement must be complete. Aperients and alteratives will be in order. 

Embolism of the Central Retinal Artery.—An embolus may lodge in 
the arteria centralis retin* or in one of its branches. 











PLATE XVI, 

Diseases cf tha RBtina, 


Fig. 1.—Embolism at Ilia Central Retinal Artery. 


Fig. 2.—Lata Appearance In a Casa at Embolism of tha 
Central Retinal Artery. (Oliver,) 


#4 


.TUX ETTA*!*? 

,i3iiilBjr atif W 

cloyed to iimdhto absorption. In 

' 


*1- R ! . ‘ (Effusion of Blood between the Retina and 

> Hood ?n ihe retina and vitreous 

• •♦tv of Chicago, writing iii 1893, said bo had 
•*y years practice. ! ’ho disease appears 

l i i f sympt'i u an eye supposed to be 
'.■> pcr.-i-pt.jnu «..i debt, which looks reddish or 
du:'-: ar. Ophthahuose ,<pic ox- 

• ; r<'« . i. > .p triform effusion, of blo<*d 

WIsItA IxaltgH J-btUibO adt la ntailncfini^—.1 .gTT l ' t! ‘ 1 I'"'' 

' he blood covered part of 
t > y & il e! • u I ron presents a darker 

oJ t f r iii are bidden by it. 

• • 

1,1 care uk* and vascular lesions 


f < 













«.^hCnTVry 

••vbff 'aloid ]»eai©rrl;»gc (Ttloxz.) 

ih*. cases, v bile in no snuilJ : onentage not any 
< niM be detected. 

of subliyaloid hemorrhage should npt be 
• '• ■'( b*h«*-*d vouid not conceal the retinal ves- 
w front of the effusion, and in sub- 
• *ni Wain of red vision. 

... ir , _ „ hemorrhage is favorable. 

PXU iq meiXoo.-.7n to aa^L! s at aoa^ijflaqqA sta.T—• 3 ,gr-J 

CuatrflO) .riaixA LsiittaH lurtdats d.'o clof, which 0 < n;v 

. 

e.r .■■ 1 r hemorrhage is.of suHment 

size to hr d: or 


redu.d eIfw 


msioi; belt 


Tanvrv 

gated ami n. ■ 
normal, As e ■ 
excitement mv. 

Embolism, <ff tin O 

the arieria centra:.* r 


>atient should be investi- 
n iepartur 1 ro. the 
,: s of stimulants and 
be in order, 
r s may lodge in 





PLATE 16 








DISEASES OF THE RETINA. 


495 


Symptoms. —The disease comes generally without pain and without 
premonitory signs, although Schobl claimed that transient obscuration of 
the visual field or transitory blindness are frequent premonitory phenomena. 
The initial symptom is sudden and complete blindness, if the central trunk 
is obstructed; sudden partial blindness, if the embolus passes into a branch 
of the central vessel. In the latter event the visual field is correspondingly 
limited. Complete blindness existing for several minutes or hours, if the 
embolus is lodged in the central artery, may be followed by a loosening 
of the plug, which then lodges in an arterial branch. Vision will then be re¬ 
stored except in the area of the visual field which corresponds to the part 
which the branch supplies. If examined immediately after the accident, 
the ophthalmoscope will show complete absence of blood from a part of or 
the whole retina, depending upon the location of the plug. The arteries are 
either completely lost to view or are much diminished in size. The optic 
papilla is whitish or yellowish. The veins are contracted, but may show 
irregular distensions toward the periphery of the retina. The veins some- 



Fig. 326.—Section of the retina in embolism of the central' artery. 

(After Marple.) 

A, Layer of rods and cones. B, External granular layer. C, Outer reticular layer. D, 

Inner granular layer. F, Layer of ganglion-cells (the ganglion-cells are almost entirely absent). 

F, Nerve-fibre layer showing marked edema. The ganglion-cells have almost entirely dis¬ 
appeared, a few nuclei only being present. There is marked retinal edema, especially in the 
layer of nerve-fibres. 

times present an intermittent flow of blood with or without pressure. Pres¬ 
sure upon the eye, by increasing intra-ocular tension, may cause a flow of 
blood, but there is usually complete absence of pulsation, venous or arterial, 
on pressure. Coagulated blood may be found in the small arteries, par¬ 
ticularly in the macular vessels. The entire fundus is white except for the 
presence, in the macular region, of a cherry-red spot (Fig. 1, Plate XTI). 
This spot has been attributed to hemorrhage, but it is now generally believed 
that it is simply the natural color of the fovea made prominent by con¬ 
trast with the white fundus. In a few hours the retina shows opacity due 
to edema. It becomes of a whitish, yellowish, gray, or greenish color except 
for the cherry-red spot at the macula. In rare cases of embolism the red 
spot may be absent; in the black races it has been observed as a black 
spot. Later on in the history of the case the retinal picture is that of 
atrophy. The arteries are extremely small, the veins are narrow and 
straight, the optic disc is white or of a dirty-grayish color, and there is 
perivasculitis and retinal degeneration. Such an eye will be blind; the 
pupil will be dilated and fixed and the media clear (Fig. 2, Plate XVI). In 








496 


MODERN OPHTHALMOLOGY. 


a few of the recorded cases of complete embolism a small sector of the visual 
field has been preserved. In such cases cilioretinal arteries were present. 

Pathology. —An embolus of the central artery lodges usually imme¬ 
diately behind the lamina cribrosa, at a point where the vessel is contracted 
and makes a turn to ascend to the papilla. Here the embolus becomes 
organized. In Marple’s case a thrombus was found behind the embolus; 
the optic nerve was atrophic, the intervaginal space was dilated, and appar¬ 
ently there was a vaginitis. Retinal changes have been found by Elschnig 
and Marple, whose cases were studied in laboratories seven weeks after the 
onset of the disease. The inner layers of the retina—layer of nerve-fibres 
and ganglion-cells—are the first to become atrophic. 

Etiology. —The cause of embolism of the central retinal artery is to 
be sought in lesions of the heart and arteries. Of 125 cases tabulated by 
Fischer, 70 per cent, showed valvular lesions, recent endocarditis, arterio¬ 
sclerosis, syphilitic endarteritis, or aneurism. In 30 per cent, no adequate 



Fig. 327.—Section through the optic nerve showing an embolus in the 
central artery. (After Marple.) 

A, Central artery of retina. At the bend of the vessel is seen the embolus. Behind 
it are a few blood-cells. B, Vein ; 0, O, Intervaginal space dilated. D, D, Chorioid. R, R, 
Retina. M, Apex of papilla. The artery here contains a large number of red blood-cells (A). 

cause could be found, but it is safe to assume that in one-half of these 
cases cardiac or vascular lesions existed without giving rise to physical 
signs. Age is not a factor, the disease being found in the young as well as 
in the old. A few cases of embolism of the central retinal artery occurring 
in chorea have been recorded b\' Swanzy, Benson, Thomas, and others. 
Embolism also occurs in Bright’s disease, and has been seen during preg¬ 
nancy. Multiple emboli of septic character due to post-partum pyemia are 
occasionally seen. In such cases, according to Galezowski, the left eye is 
more often affected than the right, but both may be involved. Septic 
emboli produce panophthalmitis, and usually cause death. In some cases 
presenting the clinical signs of embolism, without discoverable cardiac 
lesions, it is possible that the true condition is a hemorrhage into the optic 
nerve-sheath. The blindness is sometimes preceded by daily attacks of 
epistaxis, as in cases reported by Jessup and Collins. 

That embolism ot the central retinal artery does not more frequently 
occur is doubtless due to the anatomic fact that the ophthalmic artery 


DISEASES OF TI1E RETINA. 


497 


branches from the internal carotid at almost a right angle, and that the 
arteria centralis retinas is given off from the ophthalmic, or from one of its 
larger branches, in turn in much the same way. Hence, a clot leaving a 
cardiac valve is much more likely to continue its course in the large vessel 
and lodge in the brain than to enter a branch given off in this manner. 
If an embolus gains access to the ophthalmic artery, it is much more likely 
to traverse the lacrimal, supra-orbital, nasofrontal, and their terminal ves¬ 
sels (the ciliary arteries) than the retinal artery. It is probable that 
embolism of the ciliary arteries is a more common affection than has been 
supposed; however, owing to free anastomoses, plugging of one of these 
vessels is not followed by such disastrous effects as 'follow embolism of the 
central artery. 

Diagnosis. —The ophthalmoscopic picture described above is pathog¬ 
nomonic of a stoppage of the retinal circulation, but this may be due either 
to embolism, thrombosis, or hemorrhage into the sheath of the optic nerve. 
Except the embolus is lodged in a branch of the central vessel, differentia¬ 
tion between these conditions may be difficult or impossible. Another 
lesion which obscures the diagnosis is thrombosis of the central vein at a 
point where it can press on and occlude the adjacent artery. According 
to Priestley Smith, arterial thrombosis can be distinguished from embolism 
by a history of transient failure of sight, resembling the permanent attack 
in its onset. Simultaneous failure of the other eye favors the diagnosis of 
thrombosis. 

Prognosis.- —This is very unfavorable. It rarely happens that the 
plug becomes displaced spontaneously or by treatment. If a branch of 
the central artery is involved, there will be loss, of vision in a corresponding 
area of the field. Septic emboli, such as are found in puerperal fever, cause 
panophthalmitis and often lead to death by reason of the planting of septic 
foci in vital parts. It is not easy to say in these cases whether the central 
retinal artery alone is involved; it is likely that emboli are also present in the 
chorioidal vessels (ciliary arteries). In embolism of a branch of the central 
artery the formation of an anastomosis was observed by Konigshofer. If a 
cilioretinal vessel is present, the plugging of the central artery will not com¬ 
pletely check the supply of blood to the retina: a limited area supplied 
by the cilioretinal vessel will functionate. While the prognosis in embolism 
is usually unfavorable, great or complete restoration of vision is possible. 
Cases have been reported in which vision was restored by deep massage 
combined with the internal use of Rochelle salts and iodid of potassium 
and hypodermic injections of pilocarpin. 

Treatment. —The indications for treatment are (1) to dislodge and 
break up the embolus and (2) to promote absorption of the clot. A patient 
with embolism of the central artery should be sent to bed and should be sub¬ 
jected to an energetic course of treatment at the earliest possible moment. 
Hypodermic injections of pilocarpin should be given; the internal use of 
salines and potassium iodid should be tried; and deep massage of the eyeball 


498 


MODERN OPHTHALMOLOGY. 


should be practiced morning and evening for a week or ten days. Hot 
compresses may be employed over the eye. Inhalations of nitrite of amyl 
may be of some use. If these measures fail, the surgeon may repeatedly 
tap the anterior chamber in the hope that the sudden reduction of intra¬ 
ocular tension will result in the dislodgment of the embolus. Massage 
is employed by placing the thumb or fingers on the closed upper eyelid, 
making deep pressure for two or three minutes. Following this the sur¬ 
geon should make an ophthalmoscopic examination to determine the effect 
of the treatment. Sclerotomy and iridectomy have been tried in embolism 
with little effect. 

Thrombosis of the Central Retinal Artery.—This condition may be 
due to cardiac or vascular lesions, or, as has been observed recently by 
Siegrist and Gifford, it may follow ligation of the deeper vessels of the neck. 
In the first of two cases observed bv Siegrist after ligation of the common 
and internal carotid arteries the eye of the same side became blind. The 
ophthalmoscopic picture was similar to that which is found in embolism and 
in thrombosis of the central retinal artery. The autopsy showed a throm¬ 
bosis of the internal carotid, ophthalmic, and central retinal arteries. In 
Siegrist's second case ligation of the internal and external carotids was 
followed by blindness, by a similar fundus picture, and by atrophy of the 
retina with pigment accumulation. 

The ophthalmoscopic picture of thrombosis is similar to that of em¬ 
bolism. Premonitory symptoms in thrombosis are attacks of transient 
blindness in both the diseased eye and its fellow, headache, giddiness, and 
faintness. These symptoms are rarely present in embolism. 

The diagnosis between thrombosis and embolism is difficult, not only 
clinicall}^ but also microscopically. Thus, of 15 cases of supposed embolism 
of the central retinal arterv which are recorded in literature as having been 
subjected to microscopic study, Marple states that in 4 no embolus was 
found, in 5 it was impossible to say whether the condition was embolism or 
thrombosis, and in only 6 was an unmistakable embolus found. It is neces¬ 
sary to study such specimens in both longitudinal and cross sections. 

Etiology. —Ann Michel attributed thrombosis to arteriosclerosis. It 
is possible that spasm of the muscular coat of the artery is an etiologic 
factor. Recently Sachs has observed the formation of a ring of constric¬ 
tion on one of the retinal arteries, which began on the physiologic cup and 
extended to the bifurcation of the artery. Similar constrictions followed 
at short intervals. The case was one presenting the ophthalmoscopic signs 
of retinal embolism and the observation was confirmed by Fuchs. Gale- 
zowski believes that, in cases of supposed embolism in which no probable 
source for the embolus could be found, the condition was really thrombosis 
due to endarteritis. 

Thrombosis of the Central Retinal Vein. —A thrombus forming in the 
central vein or in its branches causes ophthalmoscopic appearances which 
were formerly credited to.embolism of the central artery or to hemorrhagic 


xvii, 

Eis£HS85 3f tfc.B Retina, 


Fig 1.— Tliramhasia □* :b.a LlaEtral Retinal Vain, 


Fig. 2 .—CnarinidaretLnitia in a Myopia Eye. 


mrx 3 T.h.jt 

'■■(I r \ !■ • ' : r. 

.iaJutaH Eii; hi SEHSBeiCT 


t r&ctv -Ki jr irmiur ort * . ■ ■ h * a week ot ten days. Hot 
employed ovi r e »\ \ nhulaiimis of nitrite of amyl 

>! If these iv< the si;••.eon may repeatedly 

: ; n tra- 

r < . v v • 11 result in Tb li ‘ohpvhuv of the embolus. Massage 
v : i.icing the •hv.mb or fibijers or the closed upper eyelid; 

, 

-houi;! dm an ophthalmoscopic exranimi.ti.on to determine the effect 
.SdeimtoTn and iri' emono* ve been tried in embolism. 

t- ■: ; it tie eilcet. 

Thromboshi of the Central iletirai. Artery.- - This, count' m n y he 

cardiac or -.ascalar la ons, or, as Lai b<en observed receid!;, >*' 

• ■ v ’• ; i and f.Jit?’Vessels of d • ; .. k. 
In lb.- tii>i o t.vo c.- - ■: observed bv Sieffrist after iination of the common 
. 

in 'ho vb sts .> Ti e u'l .x retinal. irtery. The autopsy - a*<1 dirom- 
boeis of ’!ii '••»«.) •’rtro-.i'h ophthalmic, and central ledna! unenee, In 
op. ’0 d ■'})& iigauoo the niorna 5 and external carotids was 

• h 1 it>r \ - a similar fundtt.? picture, and by atrophy of the 

at : •cumulation. 

'pic picture of thrombosis is similar to that of ?;a- 
lb • >ry yn..items in thvimbosis are attacks of transient 
■ *hi uv i,u) :e diseased e arid il fellow, headache, giddiu- anil 

i ftmns ire rare!} preset! t in 

• > ' »•!'! ro**t»os:.s and emboli on is difficult, not only 

- u mu ally. Tims, of 15 ease-' of supposed embobr-m 


■•- -• i ..- , . 


.Min.'n are recorded in literature as having been 


)B po- 
facie: r 


.u- iy, f'.irple states that m 4 no embolus was 

- ' ’ io to saj .whether tl q was embolism or 

“•> . was an uaw is.' akable embol as found. It is neces- 

; * r ? c -‘Oth longitudinal and . ross sections 

’■ _ ihutod thrombosis to an ’ ic:?clerosis. It 

inn n ar coat of the nr,- .ry is an eliologie 
the formation >i. g of constric¬ 
tion on mi 
ei 

at Short i?i. orvai 4 -' 
of* retinal c« «•• a 
zowski belie- - * 
source for me oi:d • 

due' to end * rer..> 

Thrombosis cf rkc 'kitten' FhumhVek; k hrombus form.;;.- i the 

'•hbfh..- - • ic appearance wl ioh 

Urn eentmi artery .or to Wmertfeakh 


•\tOnc.:-l v. : i * - Sinii trd-'fvflsfnj ■■ i* 'd- id 


. !.> ifi: 


unit 


ting the ophtl il .. . ' 

■e- conlirmeb. y.» i.* 

olism in which 

t e dition wis resjl y *M 


■ v i »s 


■■il -hie 


.bosis 


central vein or ; n its 
were ‘onnerly credited to *n 



PLATE 17 

















































'» 


















) 


















DISEASES OF THE RETINA. 


499 


retinitis. Possibly some of the reported cases of hemorrhagic retinitis 
were examples of thrombosis. Phlebitis of the cavernous sinus, which 
might be expected to cause ophthalmoscopic signs, rarely does so because 
of the free communication existing between the orbital and facial veins. 

Symptoms. —In complete closure of the central vein by a thrombus 
the retinal veins are dilated and tortuous, the margins of the optic disc are 
blurred and indistinct, but the disc itself is usually not much swollen. 
Around the disc is a striated area of blood-extravasation into the nerve-fibre 
layer of the retina; and numerous hemorrhages are found in the periphery 
(Fig. 1, Plate XVII). The arteries are small and few in number. The 
veins may show on their convexity a light-streak, while the concavity is hid¬ 
den in the edematous retina. Vitreous opacities soon appear, and vision be¬ 
comes much reduced. In favorable cases the vitreous clears, the hemorrhages 
disappear by absorption, and useful vision may be retained. Some cases 
show in the macular region a yellowish-gray opacity presenting a cherry-red 
spot in its centre. Such cases simulate embolism. Vision may be com¬ 
pletely lost in thrombosis by repeated hemorrhages. If the thrombus be¬ 
comes dissolved or a canal forms alongside it, the fundus will gradually 
become clear. 

In incomplete closure of the central vein or in closure of one of its 
branches, a less extensive, but similar, retinal picture is seen. There are 
a few hemorrhages on the disc-margin or in a peripheral part of the retina. 
There may be in the mildest cases only a few tuft-like hemorrhages radiating 
from the disc. Such cases may improve and visual acuity may be restored. 
Often, however, such lesions occur repeatedly, and glaucomatous symptoms 
supervene, the case ending in an enucleation for the relief of pain. In 
thrombosis of a branch of the central vein the retinal changes are limited 
to a corresponding area. 

Diagnosis. —The diagnosis of thrombosis of the central retinal vein 
may present many difficulties. The following table by Frost contrasts the 
ophthalmoscopic appearances of thrombosis and embolism:— 


Thrombosis of the Central Vein. 

1. Arteries: calibre normal or slightly 

diminished. 

2. The veins are tortuous. 

3. Veins turgid, and appear interrupted 

(from being buried in the retina). 

4. Venous pulsation on pressure. 

5. Extensive retinal hemorrhage. 


Embolism of the Central Artery. 

1. Arteries filiform. 

2. Course of veins normal. 

3. Veins decrease toward the disc 

(blood-column may be broken into 
segments). 

4. No pulsation. 

5. No hemorrhages, or very few. 


Prognosis. —This will depend on the location of the thrombus and 
whether it becomes speedily dissolved or remains, completely occluding the 
lumen of the vessel. In general terms it may be said that complete restora¬ 
tion of visual acuity is scarcely to be expected. 

Treatment. —This is unsatisfactory. Venesection, rest, and the use 
of salines may be tried. 



500 


MODERN OPHTHALMOLOGY. 


INFLAMMATION OF THE RETINA. 

Inflammations of the retina may be divided into (1) simple, or serous 
retinitis, (2) parenchymatous retinitis, and (3) purulent (septic or em¬ 
bolic) retinitis. Certain affections of the retina, of which the so-called 
retinitis pigmentosa may be taken as the type, will be considered under the 
heading of “Retinal Scleroses.” 

SIMPLE, OR SEROUS, RETINITIS. 

This affection is sometimes called edema of the retina. It is charac¬ 
terized by a limited or general opacity of the retina; by increased size 
and tortuosity of the vessels, particularly of the veins (which may be some¬ 
what obscured by the retinal edema) ; and by diminution in visual acuity 
in that part of the field of vision which corresponds to the diseased area. 



Fig. 328.—Serous retinitis. (Oliver.) 

Hemorrhages are not often found in serous retinitis. Distortion of vision 
may be present. Thus, objects may appear too large (megalopsia) or too 
small (micropsia). The patient may see better by reduced illumination 
or toward evening (nyctalopic retinitis of Arlt). The disease may be 
unilateral or bilateral. It may be caused by trauma (retinitis from con¬ 
cussion), by eyestrain, or by certain constitutional conditions (syphilis), 
or may be due to unknown causes. Other forms of retinitis may begin as 
serous retinitis, and will naturally be classified as such until their special 
features become demonstrable. The papilloretinitis accompanying sym¬ 
pathetic ophthalmitis is of the serous variety. Although ophthalmic writ¬ 
ers have treated of several varieties of serous retinitis, the author will 
consider only one form: syphilitic retinitis. 

Diagnosis.—The diagnosis of serous retinitis must rest on the ophthal¬ 
moscopic findings, the absence of appearances characteristic of the paren- 










DISEASES OF THE RETINA. 


501 


chymatous and embolic forms of retinal inflammation, and the history of 
the case. The blurring of the fundus found in astigmatism and the hazi¬ 
ness due to fine vitreous opacities are sometimes causes of errors in diag¬ 
nosis. 

Prognosis.—The prognosis of serous retinitis is favorable. 

Treatment.—The treatment will include removal of the cause, the cor¬ 
rection of errors of refraction, the local use of atropin and smoked glasses, 
and attention to the general health. The correction of constipation, indi¬ 
gestion, etc., is of importance. A patient with serous retinitis should not 
be kept in a dark-room, nor, on the other hand, should he be exposed to 
bright light. 

Syphilitic Retinitis (Specific Retinitis).—Although this disease is 
sometimes serous and at others parenchymatous, it will be described in this 
place. The question of the existence of an inflammation of the retina, 
caused by syphilis and independent of chorioiditis, has been much dis¬ 
cussed by eminent ophthalmologists. In recent years the question has been 
decided in the affirmative. The condition known as diffuse syphilitic 
chorioidoretinitis, the diffuse syphilitic chorioiditis of Forster, is charac¬ 
terized by the presence of fine, dust-like opacities in the posterior part of 
the vitreous, Chirring and redness of the optic papilla, and by alterations 
in the macular region and in the vessels. 

The diffuse syphilitic retinitis of Jacobson is a later secondary mani¬ 
festation of syphilitic infection, appearing six months to two years after 
the primary infection. The disease, however, may result from hereditary 
syphilis. It may be unilateral, but usually is bilateral. Other forms of 
syphilitic retinitis which have been described by competent observers are: 
(1) relapsing syphilitic central retinitis, (2) syphilitic hemorrhagic.reti¬ 
nitis, (3) syphilitic arteritis of the retina, and (4) syphilitic perivasculitis 
of the retina. The first of these is a rare disease which is characterized 
by relapses and by ophthalmoscopic signs limited to the macula. Vision 
is often suddenly reduced, but improves markedly during the intervals, 
although after repeated attacks it may be permanently diminished. The 
macula looks gray or grayish-yellow, and may show small, white points 
arranged in groups. Pigment-spots appear after the disease has lasted for 
several years. Micropsia has been noticed in these cases, and sometimes the 
disease passes into diffuse syphilitic retinitis. 

Syphilitic hemorrhagic retinitis, also a rare affection, is characterized 
bv opacities in the posterior part of the vitreous humor and by numerous 
hemorrhages of various sizes and shapes. The arteries are small, and the 
veins are enlarged and tortuous. 

In syphilitic arteritis of the retina the arteries appear as narrow gray or 
white bands and finally disappear, the pathologic process being an endar¬ 
teritis obliterans. The veins are enlarged. The cerebral arteries in most 
cases are involved in a similar obliterative inflammatory process. In many 
of the cases few retinal symptoms are present; the vision is not much re- 


502 


MODERN OPHTHALMOLOGY. 


duced; opacities in the vitreous, redness of the nerve-head, and blurring of 
its margins are not marked; and night-blindness is absent. 

Syphilitic perivasculitis of the retina, also known as syphilitic peri¬ 
phlebitis of the retina, has been described by Scheff'els. The papilla is 
red; the veins are enlarged and tortuous, and are surrounded by dark-red 
hemorrhages. The arteries may be normal and the retina transparent. 

Pathology.— Nagel, who has made careful studies of eyes the seat of 
specific chorioidoretinitis, found localized adhesions between the chorioid 
and retina. About these points of adhesion the chorioid was degenerated, 
the choriocapillaris being entirely destroyed. Usually the retinal changes 
are more advanced than those of the chorioid, but the reverse may be true. 
The outer layers of the retina are destroyed at many points, while the inner 
layers show masses of irregularly arranged pigment. Muller’s fibres are 
thickened, and the blood-vessels show marked inflammatory thickening. 
There are many points of similarity between the anatomic changes of specific 
chorioidoretinitis and those of retinitis pigmentosa. 

Diagnosis. —The diagnosis of these conditions must be made ophthal- 
moscopically and by attention to the patient’s history or by the finding of 
other syphilitic lesions. The exclusion of other causes of retinitis will aid 
in the diagnosis. 

Prognosis. —Syphilitic retinitis is a chronic disease, although at times 
the onset is sudden. The prognosis will depend largely upon the time at 
which treatment is begun. Under energetic use of proper remedies great 
improvement can be expected; but when treatment has been delayed there 
are likely to be grave retinal and chorioidal lesions, with corresponding 
loss of vision. 

Treatment. —The use of mercurial preparations by inunction or by 
the mouth is of the highest importance, and the remedy must be pushed 
to the limits of tolerance. At the same time attention should be given to 
the digestion and nutrition. The eyes may be protected by dark glasses, 
and in the acute stage a mydriatic may be used. In the later stages the 
use of iodid of potassium is to be advised. 

PARENCHYMATOUS RETINITIS. 

While in serous retinitis the changes are limited to hyperemia and 
edema, in the parenchymatous form hyperplasia is added to these altera¬ 
tions, and the deeper layers of the retina are involved. Occasionally both 
the serous and parenchymatous forms exist in the same eye at the same time. 
The causes of parenchymatous retinitis may be easily determined when the 
disease depends on renal or blood alterations or on cerebral lesions. In 
some cases no cause can be found. The pathologic changes include hyper¬ 
emia, edema, round-cell infiltration, fatty degeneration, hemorrhages, and 
hyperplasia of connective tissue, with atrophy of the ganglion-cells. The 
walls of the capillaries undergo degeneration. The process may end in one 
of three conditions: (1) absorption, leaving the retina practically unim¬ 
paired; (2) partial atrophy; or (3) total atrophy of the retina. 


DISEASES OF THE RETINA. 


503 


The prognosis of parenchymatous retinitis is always serious. The 
treatment is that outlined above for serous retinitis, with the addition of 
such measures as will be mentioned later. 

Parenchymatous retinitis may be divided clinically into the following 
varieties: (1) leucocythemic retinitis; (2) diabetic retinitis; (3) albu¬ 
minuric retinitis; (4) gouty retinitis; (5) symmetrical macular changes in 
infancy; (6) circinate retinitis; (7) solar retinitis; (8) punctate condi¬ 
tions of the fundus. 

Leucocythemic Retinitis (Leukemic or Splenic Retinitis).—Retinal 
changes, which occur in about 30 per cent, of cases of leucocythemia, have 
been divided into (1) leukemic papilloretinitis and (2) retinal hemorrhages 
or hemorrhagic retinitis in leukemic eyes. The disease occurs most fre¬ 
quently in splenic leucocythemia and as a late symptom. The characteris¬ 
tic features of splenic retinitis are the orange-yellow color of the fundus, 
the tortuosity and increased diameter of the veins, the presence of white 
spots with red borders in the fundus, and the presence of hemorrhages of 
various kinds and shapes (Fig. 2, Plate XV). Often there is papillitis, 
which may be slight or marked. The affection is always bilateral and is 
incurable. The diagnosis, if in doubt, can be confirmed by a microscopic 
examination of the blood. 

Among the complications of leucocythemic retinitis may be mentioned 
chorioidal and vitreous hemorrhages, inflammation of a part or all of the 
uveal tract, hemorrhagic glaucoma, and exophthalmos from lymphomatous 
growths in the orbit. 

Treatment of these cases must be directed to the improvement of the 
general condition of the patient, and is practically without value. 

Diabetic Retinitis (Glycosuric Retinitis).—Retinal change due to dia¬ 
betes is of rare occurrence and is of such doubtful individuality that some 
prominent ophthalmologists have questioned the propriety of assigning to 
it a separate place among affections of the retina. As regards the frequency 
of ocular affections associated with glycosuria, the reports of different ob¬ 
servers vary greatly. Hirschberg believes that the ocular changes are often 
overlooked. Lagrange, among 20,000 eye cases, found 53 with diabetes; 
and, of 100 diabetic patients, W. O. Moore found 21 with ocular diseases, 
5 having retinitis. Visual disturbances may occur in diabetes without 
ophthalmoscopic signs (amblyopia of diabetes). While it is usually bi¬ 
lateral, there are no pathognomonic signs. It is an uncommon disease, 
Schobl, in a rich clinical experience, having met with only 9 such cases. 
From the writings of Hirschberg and others it is evident that diabetic 
retinal affections are divisible into five classes: (1) central punctate dia¬ 
betic retinitis; (2) hemorrhagic diabetic retinitis; (3) diabetic albu¬ 
minuric retinitis; (4) albuminuric retinitis in the eyes of diabetic subjects; 
(5) atypical diabetic retinitis. The retinal changes occur late in the dis¬ 
ease and usually in diabetes mellitus, but have been seen also in diabetes 
insipidus. As a rule, diabetic retinitis shows more hemorrhages and a 


504 


MODERN OPHTHALMOLOGY. 


smaller number of white plaques than does albuminuric retinitis. Groe- 
nouw and Uhthoff state that vitreous opacities, which are not found in 
albuminuric retinitis, may play an important role and may lead to blind¬ 
ness in diabetic retinitis. The descriptions given by various authors of the 
ophthalmoscopic appearance of diabetic retinitis are very different, and all, 
to a certain extent, resemble the findings in albuminuric retinitis. 

In the central punctate form of diabetic retinitis the optic nerve is 
not affected, while in the posterior pole the fundus shows numerous ivory- 
white spots, streaks, or points surrounding the macula in an irregular 
manner. The stellate figure found in albuminuric retinitis is wanting. 
The spots may be round, ovoid, irregular, or semilunar in shape, and may 
present serrated margins. They are more frequently found on the temporal 
than on the nasal side of the optic disc. The white spots may remain for 
years. They do not coalesce, and between them are seen small hemorrhagic 
spots. The vitreous is clear, there is no change in the pigment, and the 
periphery of the fundus is unaffected. In hemorrhagic diabetic retinitis 
there are numerous hemorrhages, but no white spots. These cases may end 
in hemorrhagic glaucoma. In the third group a composite picture exists, 
formed of the white spots of the diabetic affection and swollen nerve-head 
and retina, together with the vascular changes of albuminuric retinitis. 
The urine of such patients,, presents sugar and albumin. In the fourth 
class the general symptoms of diabetes exist with the ophthalmoscopic 
picture of albuminuric retinitis. In the atypical form cases have been de¬ 
scribed which seem to be pigmentary retinitis with subsequent accidental 
development of diabetes. Contraction of the visual field and night-blind¬ 
ness are present. Schobl saw a case—in a patient whose urine showed 3 
per cent, of sugar and no albumin—in which large white plaques were 
numerous in the periphery of the fundus, while irregular clusters of small, 
white spots were found in the macular region. Some cases of diabetic 
retinitis show atrophy of the optic nerve, hemorrhages and opacities in the 
vitreous, amblyopia, scotomata, chorioiditis, and hemorrhagic glaucoma. 

Fathology. —In a case of diabetic retinitis Nettleship found a hyalin 
degeneration of the intima in the small arteries-of the retina, the brain, 
kidneys, etc. All the layers of the retina, and particularly the nerve-fibre 
layer, were thickened by chronic edema and hypertrophy of the supportive 
connective tissue. The nerve-fibre layer showed varicosities, and the small 
retinal arteries presented miliary aneurisms. Yon Michel has reported 
glycogenic degeneration of the retina in diabetes. 

Diagnosis. —Frequently the diagnosis cannot be made with the oph¬ 
thalmoscope alone. An examination of the urine will reveal the true nature 
of the case. Specific chorioidoretinitis and retinitis punctata albescens may 
cause confusion. Attention to the general symptoms of the patient and 
repeated examinations of the urine may be required to clear the diagnosis. 
The ophthalmoscopic differences between diabetic and albuminuric retinitis 
have been tabulated by Dodd, as follows:— 


PLATE. XyilL 



Pig, 2.—iSltumimiriQ Retinitiat (Halcsr.) 



.IIIVX 3TAJ=I 


sot 


^IOj, -i:a.'49>I Brit to ZBBB^iCL 


- numl' ■■ of white pio »>• 

)>■ i > and [ilithoff atnto h.u •. •.* 
:*.‘i)UM»innric retinitis, i»v ; 
n m m diabetic re: n 
■ tlmlmoscopic < 

,o a certain c\{ 

J n the < n 




• ibumimiric retinitis. Groe- 
s, which are not found in 
n: role. and may lead to blind- 

,:,ven by various authors of the 
untie are very different,.and all, 
n albuminuric re.u nit is. 
tic retini - the'optic nerve is 


no. affected, n 
white spots, 
manner. T 
The spot v : 

than on the 




■ fund 03 s 1 f-6 numerous ivory- 
tfudiug f nri • - a in >n is: - . liar 
albGuiim tiivHs i-- v ;■«nting, 

.". or semihn in shape, a .d may 

tiurwriH oit9rfxsitT A f.i n*i " mninoru i 


»f i : e. 


years. Tie- ■' <oalesce. 

periphery of Use fundus is in 

. 

in he to rhogic glaucoma. In 
formed • : ; • white spots o: 
a ad retina, tope the; with ' 
of snob nation'.~ 










• titur 


The whi may remain for 

them are seen small hemorrhagic 
change in the pigment, and the 
. ; her oi logic dia \ ir.itis 

o g of?. These c; end 

‘ 

> arid swoli'.-;: no. so- erd 

i Ibuitrinurh retinitis. 

In t!;e fourth 


: ; • u >>-i'Opic 
.. ; . u ! - v - 






.retini*;' sho\i acr c* l 
v It r * a . amid;. ■ . . 

Datiiomwv.-- Ir a 
degeneration of the int o.a r. 

Vidimj-, etc. All the la) ms <■. ■ 

layer, v ere thickened by . ! ""pi . 

Conmv; ive {i - - u> T atoti-tUmuTim.— s .gtv 

retinal arteries presented miliar; ancuv t 
glycogenic degeneration of the retina in diat> 
in iuvosi''.— Frcqnenti y the diagnosis ■ ... 





: i c omfv. 

hyalin 
the brain. 
. 

upportive 
toe small 
• reported 




ith the oph- 
■ true nature 
tii seen * m-av 


th.-d r--.cope alum An examination of the nrin • 

>1 i;<* .•'»•>. ehorio dondinitis and retiSS' is ; 

' o >•. Alo ution >•) the general sxniptoir. mu Yet . id 

r< fa ;U< ■ v u.'iun: ions of Urn urine may be required to clear m diagnosis. 

. 

have 1«‘< i 'abuiated b\ liod'3 as follows:— 




PLATE IS 










DISEASES OF THE RETINA. 


505 


Diabetic Retinitis. 

1. Groups of bright, glancing spots in 

the retina, irregular in outline, 
usually in the central part, but 
frequently affecting the whole of 
the fundus. 

2. If the spots are large there still exist 

small dots and lines, and they never 
run together. 

3. The arteries and veins are not much 

changed in appearance. 

4. The optic neiwe is either not affected 

or is atrophic. 

5. The retina is not diffusely affected. 


Albuminuric Retinitis. 

1. At first a group of bright, bluish- 

white spots is present in the centre 
of the retina, often forming a stel¬ 
late patch about the macula. 

2. The spots may run together and 

involve all of the central part of 
the retina. 

3. The arteries are narrowed; the veins 

arc large and irregular. 

4. The optic nerve is swollen and its 

outline is indistinct. 

5. The retina is infiltrated. 


Prognosis. —As a rule, retinitis is a late and serious symptom in 
diabetes. While the retinal affection probably never causes complete blind¬ 
ness, except when glaucoma follows the hemorrhagic form, yet there is 
considerable loss of vision and the outlook for improvement is not favor¬ 
able. While it is nearly always binocular, one eye may progress much more 
rapidly than the other. In the hemorrhagic glaucoma of diabetes the 
prognosis is most unfavorable. 

Treatment.— This is simply the treatment of the general condition, 
and is sufficiently explained in works on the practice of medicine. 

Albuminuric Retinitis (Brig’ht’s Retinitis; Renal Vascular Retinitis; 
Retinitis Gravidarum).—In 1827 Bright called attention to the loss of 
vision accompanying renal diseases; in 185G the retinal changes were first 
observed in the living eye by He} r mann; and in 1859 Liebreich gave an 
accurate description and an ophthalmoscopic picture of the fundus changes 
of albuminuric retinitis. 

Etiology.— Of 935 cases of kidney disease, tabulated by Groenouw 
and Uhthoff, albuminuric retinitis was present in 209, or 22.4 per cent.; 
Wagner met it in 6 per cent, of his cases, while in Ctalezowski’s cases 31 
per cent, showed albuminuric retinitis. While the disease has been ob¬ 
served, a few times in children, as a rule the patients are over 40 years 
of age, and the majority are between 40 and 50 years old. Men are more 
frequently affected than women in the proportion of about 7 to 3. As 
regards the form of kidney lesion present in albuminuric retinitis, the 
small contracted kidney is the most frequent; chronic diffuse parenchyma¬ 
tous nephritis (large white kidney) forms a close second; the nephritis of 
scarlatina is third; and the least frequent are the rare cases of amyloid 
degeneration. As a rule, both eyes are involved in the retinal changes, and 
it rarely happens that the second eye remains entirely well for the period of 
a year. 

According to Porter, in the majority of cases of renal disease there is 
no disease of the retina; and a majority of renal cases showing retinal 
changes also show changes in the blood-vessels. He concludes that the eye 
disease does not depend so much on the existence of the renal affection as 



506 


MODERN OPHTHALMOLOGY. 


on the fact that the vessels are diseased. Almost without exception the 
cases of albuminuric retinitis which he observed were found in syphilitics. 
Owing to vascular changes incident to syphilis, hemorrhages and fatty 
degenerations are to be expected in the retina. In nearly four thousand 
post-mortem examinations he has never seen one-sided nephritis. Some 
foreign authors have contended that in unilateral albuminuric retinitis only 
one kidney is diseased. 

Symptoms. —Persons with nephritis often complain of morning head¬ 
ache, nausea, vomiting, etc. The defect of vision is an early symptom, but 
comes with a late stage of the renal disease, and often with a dilated left 
cardiac ventricle. Albuminuric retinitis comes after vascular tension has 
been long increased and elimination begins to fail, and, although appearing 
as a late sign, it is often the first symptom which leads to a correct diagnosis. 

The ophthalmoscopic signs of albuminuric retinitis include vascular 
changes, hemorrhages, white spots, exudations, and optic neuritis (Fig. 2, 
Plate XVIII). These changes are found chiefly in the posterior pole. The 
optic-nerve head is reddened, its boundaries are ill defined, the veins are 
broadened and tortuous, and the arteries are narrowed. The retina about 
the papilla looks grayish and opaque, and small hemorrhages are visible. 
The arteries often show white streaks on both sides of the red blood-column. 
In some cases papillitis occurs either in the beginning of the ocular disease 
or long after the appearance of the retinal changes mentioned above. In 
these cases probably there is often a coexistent bram-lesion with increased 
intracranial pressure, and a fatal result is to be expected. Papillitis, how¬ 
ever, can occur in albuminuric retinitis without brain-lesion. 

If, as is often the case, the preliminary stage of hyperemia is absent 
or is not observed, glittering white patches form the first sign in the 
retina. They are often arranged in groups surrounding the papilla like 
a ring and coalescing form large white spots. The inexperienced observer 
may mistake this condition for opaque nerve-fibres in the retina. Both 
present large white plaques passing from the papilla, but in the congenital 
condition (opaque nerve-fibres) signs of inflammation are absent. The 
exudation of a recent chorioiditis is to be distinguished from albuminuric 
retinitis by the less brilliant whiteness of the patches, and by the fact that 
they are accompanied by vitreous opacities and pigment collections, while 
hemorrhages are absent. In the macular region the white spots frequently 
form a stellate figure. Hemorrhages are found in great variations. In some 
rare instances the retinal change is present as a retinitis hemorrhagica, and 
the white spots are either entirely absent or are present in small numbers. 
In other rare cases the spots are found in the chorioid as well as in the 
retina, and pigmentation is present. These are cases of primary inflam¬ 
mation of the uveal tract. The frequency of involvement of different 
portions of the retina has been estimated by Schlesinger. He found hem¬ 
orrhages and typical lesions in 77 per cent, of all cases of albuminuric reti¬ 
nitis, white spots alone in 14 per cent., and involvement of the papilla alone 


DISEASES OF THE RETINA. 


507 


in 7 per cent. The ophthalmoscopic picture is thoroughly typical when 
both the disseminated white spots and the stellate figure at the macula are 
present, but an exactly similar picture is sometimes seen, together with 
papillitis, in some cases of sarcoma of the brain without kidney-lesions. 
According to Laqueur, the same is true of some cases of diabetes mellitus, 
and also of patients whose urine never contained albumin. A similar 
picture may be found in poisoning, anemia, and syphilis. The white 
stellate figure at the macula is not always characteristic of kidney-lesion. 
On the one hand, it may be absent in albuminuric retinitis, and, on the 
other, it is sometimes seen in cases where albumin is never present in the 
urine. 

The visual disturbances of this disease comprise a greater or less loss 
of visual acuity, without, as a rule, contraction of the field of vision and 
without loss of the color- and light- senses. Central scotoma is often pres¬ 
ent. The loss of vision is usually slow, rarely rapid, complete blindness being 
seldom observed. If it suddenly occurs in both eyes, it is suggestive of 
uremic amaurosis; if unilateral blindness or great loss of vision occurs 
rapidly, the case is likely one of embolism of the central retinal artery. 

Albuminuric retinitis may show improvement or even complete cure, 
but many patients die before the retinal disease undergoes retrogressive 
changes. If the kidney-lesion improves, the surgeon may hope for improve¬ 
ment in the ocular condition. In some cases the retina improves regardless 
of the extension of the renal affection. Retinal improvement, when it 
occurs, is slow, and the stellate appearance of the macula is the last to 
disappear. The optic-nerve head may become whitish and atrophic and 
useful vision may remain. Some cases show alternating loss and improve¬ 
ment of vision for a long period. Complete blindness as a result of this 
disease is extremely rare. Complications are not common, and include 
detachment of the retina, hemorrhage into the vitreous humor, hemorrhagic 
glaucoma, and embolism of the central retinal arterv. 

Pathology.— The anatomic changes in albuminuric retinitis are found 
chiefly in the posterior pole, rarely reaching forward as far as the equator, 
and never involving the ora serrata. They consist of edema and inflamma¬ 
tory deposits. The edema accounts for the diffuse cloudiness which is visible 
ophthalmoscopically. The blood-vessels, not only of the retina, but also 
of the uveal tract, frequently show sclerotic or hyalin changes in their 
walls. The radial fibres of Muller undergo proliferation, and their inter¬ 
stices are filled with a fibrinous deposit. In the retinitis albuminurica of 
pregnancy changes in the retinal vessels are occasionally absent (Silex). 

Hemorrhages occur into the retina and at times break through into the 
vitreous humor. The white spots, which are visible with the ophthalmo¬ 
scope, depend on granular or fatty degeneration of the supporting tissue 
(Duke Carl Theodor, Leber) ; upon fatty degeneration of cells, particu¬ 
larly in the two granular layers; or upon the presence of foci of varicose 
hypertrophied nerve-fibres. The stellate figure in the macular region de- 


508 


MODERN OPHTHALMOLOGY. 


pends chiefly upon fatty degeneration of Muller’s supporting fibres, which 
radiate from the fovea centralis, and here do not, as in other places, push 
through the retina. Weeks questions this explanation. His researches 
lead him to believe that the changes in Muller’s fibres are due to post¬ 
mortem alterations. The chorioid on microscopic examination shows simi¬ 
lar changes, viz.: lesions of the vessels and inflammatory changes. 

In the optic nerve, together with hypertrophy of the connective tissue, 
there is edema or pronounced inflammation. Generally the inflammatory 
changes involve only the papilla and end at the lamina cribrosa, without 
further extension centrally. Gurwitsch found hyalin bodies in the head 
of the optic nerve and in the granular layer of the retina. 

The cause of retinal detachment in albuminuric retinitis is explained 
by Leber and Ivordensen in this manner: the small elevations, especially 
around the papilla, depend on a primary exudation into the subretinal 
space, while further detachment can be attributed to shrinking of the 
vitreous humor. 

Diagnosis. —In typical cases the diagnosis of albuminuric retinitis 
is not difficult, but it must be remembered that, while the ophthalmo¬ 
scopic picture is highly suggestive, it is not pathognomonic, similar fundus 
changes being met with in rare instances in cases of intracranial tumor, 
lead encephalopathy, pachymeningitis hemorrhagica, anemia, syphilis, and 
diabetes mellitus. 

Tumor of the Brain, as a rule, is easily distinguishable from Bright’s 
disease. However, in some cases of cirrhotic kidney there is little or no 
dropsy, headache and vomiting are often prominent and distressing symp¬ 
toms, and pain may be most severe in the back of the head; epileptiform 
convulsions and even hemiplegia may be present, while the ophthalmo¬ 
scopic changes may be similar to those found in cerebral tumor. 

In the differential diagnosis it will be necessary to give attention to 
the following points:— 

1. The condition of the urine. While the finding of albumin and 
tube-casts will clear the diagnosis, in some cases of cirrhotic nephritis 
albumin may be scanty or entirely absent and-tube-casts may be so few as to 
escape detection. 

2. Condition of the heart and great vessels. In all forms of Brioht’s 
disease, except possibly in the pure form of waxy kidney, the blood-pressure 
is high, the arteries are atheromatous, and the left ventricle is hyper¬ 
trophied. In the absence of a valvular lesion these symptoms are highly 
suggestive of renal disease. 

3. Ophthalmoscopic changes. “The ophthalmoscopic changes, per se, 
can never be taken as an absolutely certain guide, for the appearances 
typical of one condition are, in some rare and exceptional cases, met with 
in the other.” (Bramwell.) 

Saturnine Retinitis .—While in most cases of chronic lead poisoning 
(which may present ophthalmoscopic changes similar to those of albu- 


DISEASES OF THE RETINA. 


509 


minuric retinitis) albuminuria is present, exceptional cases have been 
observed by Forster, Rosenstein, and Lehmann. The diagnosis between 
albuminuric and saturnine retinitis must rest on the following data: (1) 
the history of the case with special reference to the patient’s occupation; 
(2) the presence of a blue line on the gums in case of lead poisoning; (3) 
the finding of lead in the urine. 

Anemia and Syphilis .—In cases of these diseases presenting ophthal¬ 
moscopic appearances similar to those found in albuminuric retinitis, the 
diagnosis may be established by an examination of the blood in the one and 
by the history and lesions of the other. 

The ophthalmoscope cannot always make a distinction between albumi¬ 
nuric retinitis and the retinitis associated with diabetes. Here an examina¬ 
tion of the urine will give correct information. Cases of hvsteric blindness 
occurring during the puerperium, especially if a trace of albumin is present, 
may cause difficulty in diagnosis. Here, however, there will be an absence 
of ophthalmoscopic changes. In all cases of suspected albuminuric reti¬ 
nitis repeated examinations of the urine should be made for albumin and 
casts. In case a mydriatic is used to facilitate the ophthalmoscopic examina¬ 
tion, the surgeon should use euphthalmin or homatropin, since their effect 
lasts only a short time. If atropin is used and the patient suffers further 
diminution of vision from progression of the disease, the surgeon may be 
unjustly blamed for the loss of sight. 

Prognosis. —Albuminuric retinitis is an indication of a serious under¬ 
lying condition, and its appearance usually indicates the early death of the 
patient. The prognosis is most unfavorable in chronic nephritis; it is 
more favorable in acute nephritis and relatively most favorable in the 
albuminuria of pregnancy. Probably 85 per cent, of all persons with 
albuminuric retinitis die within two years. A few live for three, four, five, 
or six years, and exceptional cases have survived for ten or twelve years. 
The social status and hygienic surroundings have an influence on the dura¬ 
tion of these cases, the poor dying sooner than the wealthy. 

The Retinitis Albuminurica of Pregnancy presents many peculiarities, 
on which account it must be considered alone. Comprehensive descriptions 
of this disease have been given by Axenfeld and Silex. The latter ob¬ 
served thirty-five cases in seven years. In this disease the loss of vision 
appears slowly in the course of weeks and months, and chiefly in primiparse 
and in the latter half of pregnancy. Exceptionally the retinitis may appear 
first in childbed. Visual acuity diminishes gradually in both eyes without 
contraction of the visual field, and without loss of the color-sense. Some¬ 
times complete amaurosis occurs, particularly if eclamptic seizures accom¬ 
pany the disease. This blindness is'traceable to uremia, and usually dis¬ 
appears. It is only when complications occur, such as detachment of the 
retina, that vision can be completely lost. In subsequent pregnancies mild 
recurrences are the rule, by each of which a further loss results. Dis¬ 
turbance of the general health may be absent; only edema is present. 


510 


MODERN OPHTHALMOLOGY. 


The ophthalmoscopic signs are the same as those found in albuminuric 
retinitis from other causes. As an early symptom Silex mentions a change 
in the central reflex streak of the arteries, which, in the upright image, 
appears broadened and of a glistening golden yellow. Yet this phe¬ 
nomenon, as Silex especially states, is found also in syphilis and in arterio¬ 
sclerosis, and hence is not characteristic of the albuminuric retinitis of 
pregnancy. The changes in the vascular reflex are attributed to an en¬ 
gorgement in the lymph-sheaths of the blood-vessels. 

Eetinitis gravidarum appears, according to Groenouw:—• 

1. In the pregnancy kidney, in which there is fatty degeneration of 
the epithelium of the uriniferous tubules. The urine in these cases is 
passed in diminished quantity and is of dark color. It is strongly albu¬ 
minous, showing hyalin, rarely granular, casts, with fatty degeneration of 
the epithelial cells. The disease occurs in from 1 to 20 per cent. Eetinitis 
albuminurica, according to Silex, occurs about once in three thousand 
pregnancies. Thompson found, among thirty cases of retinitis albuminu¬ 
rica observed by himself, four that were due to pregnancy. 

Furthermore, albuminuric retinitis can occur 

2. If an acute nephritis accidentally originates during pregnancy, or, 
finally:— 

3. If an old chronic nephritis becomes unfavorably influenced by 
pregnancy. In the two examples last named, pregnancy is not the cause, 
but is only a complication, of the kidney affection. The pathologico-ana- 
tomic findings in the albuminuric retinitis of pregnancy are the same as 
those found in other instances, only involvement of the vessels is either 
entirely absent or is insignificant. 

The prognosis as regards life and vision in cases of albuminuria is 
most grave when a chronic nephritis exists, since most of these patients 
die within two years; it is better in acute nephritis, since complete cure 
of the eye and kidney symptoms may occur; and is most favorable in 
pregnancy kidney (albuminuria due to pressure). Of twenty-one cases 
of retinitis gravidarum, Silex saw a complete disappearance of the retinal 
changes in two cases; the other cases presented permanent retinal changes 
either in the form of small white spots or as pigment degeneration in the 
macular region. Persistent loss of vision points to a complication, such as 
retinal detachment or atrophy of the optic nerve. Partial atrophy of the 
optic nerve was observed by Forster in three of four women with retinitis 
gravidarum who were delivered during eclampsia. 

If, however, premature labor is induced, the prognosis is much more 
favorable as regards vision. Without the induction of premature labor 
the prognosis is most serious. Howe, in an analysis of cases extending over 
a period of fifteen years, says: “These tend to show that, when the vision 
begins to be impaired only in the last two weeks of pregnancy, recovery 
follows almost invariably. Of those described as being in the eighth month 
or thereabouts, when the retinitis commences, not one-half recovered, and 


DISEASES OF THE RETINA. 


511 


several did not materially improve. Again, when this began earlier than 
was estimated,—as the middle of the seventh month, when Nature did 
not interfere by bringing on a miscarriage, and when the patient escaped 
with her life,—it was only to remain blind forever afterward.” 

Treatment. —The treatment of retinitis albuminurica must be gov- * 
erned by the fundamental disease. Sudorific and purgative treatment will 
be in order. A long-continued use of potassium' iodid, citric acid, and 
similar remedies has proved of value. The diet should be nutritious but 
non-stimulating, milk diet being preferred. The patient’s strength should 
be kept up by preparations of iron. If the cause of the kidney-lesion can 
be determined,-—such as malaria, syphilis, or lead poisoning,—it should 
receive appropriate treatment. The use of mercurials, however, must be 
carefully watched lest harm result. Cupping may be used, but is of doubt¬ 
ful value. The use of alcohol, coffee, tea, and tobacco is to be interdicted. 
To improve the retinal circulation efforts to reduce intra-ocular tension 
by means of instillations of 1-per-cent, strength solution of pilocarpin or 
Vo-per-cent. strength solution of eserin may be tried. 

The albuminuria of pregnancy demands careful attention from the 
family physician. The question whether premature labor should be induced 
should receive careful consideration. Many surgeons believe that where 
there is progressive failure of vision from retinal changes premature labor 
is justifiable; and, when a preceding pregnancy has left the patient with 
permanent loss of vision, abortion should be produced. 

Gouty Retinitis.—Elderly subjects with the gouty diathesis often 
present lesions of the retina and retinal vessels. There is usually pro¬ 
gressive impairment of vision of both eyes. Bull states that while the loss 
of central vision is marked, peripheral vision is little impaired, and gouty 
retinitis never ends in blindness. Ophthalmoscopic examination shows 
patches of yellowish-white exudation in the macular region and adjacent 
to the optic disc; hemorrhages, which occur for the most part in the early 
stages of the disease; opacity and thickening of the vessel-walls; and 
irregularity in the calibre of the arteries and veins. These patients show 
general arterial sclerosis. The urine is of high specific gravity. It con¬ 
tains an excess of uric acid and some albumin, but no casts are found in 
uncomplicated cases. The ophthalmoscopic picture is not sufficiently char¬ 
acteristic for diagnosis, which, however, can be readily determined by 
exclusion. The pathologic changes in this disease include extensive arterio¬ 
sclerosis and phlebosclerosis, with obliteration of the smaller arterial 
branches; degeneration of the retinal layers and particularly thickening 
of the nerve-fibre layer of the retina from the presence of granular bodies; 
varicosities of nerve-fibres and changes in the chorioidal vessels similar 
to those found in the retina. The prognosis is usually favorable as regards 
the retention of the amount of vision existing at the time of examination, 
but much depends upon the willingness of the patient to adopt dietetic 
and medicinal treatment. Many of these patients die from cerebral hemor- 


512 


MODERN OPHTHALMOLOGY. 


rliage. The ocular treatment will include rest and the wearing of proper 
glasses. The general treatment is sufficiently described in works on the 
practice of medicine. 

Symmetrical Macular Changes in Infancy (Infantile Amaurotic 
Family Idiocy; “Rare Fatal Disease of Infancy with Symmetrical Changes 
in the Macula Lutea,” Kingdon).—In 1881 Waren Tay reported the case 
of a child, aged 12 months, who was mentally deficient and who presented , 
symmetrical changes in the macula. When first examined the optic discs 
were normal, while at the macula there was a diffuse white plaque, in the 
centre of which a brownish-red spot stood out, thus resembling the ophthal¬ 
moscopic picture of embolism of the central retinal artery. Five months 
later the spots remained the same, but the optic discs were atrophic. 
Since Tay’s observation about seventy cases have been reported. The chil- 



Fig. 329. —Macular change in infancy. (Tay.) 


dren are born healthy; at the end of several months sluggishness and 
somnolence are noticed; there is gradual loss of vision; the child makes 
irregular and purposeless movements; it is unable to hold itself erect; the 
indications of weakness increase, and the end is death by marasmus. Only 
one case is known to have lived longer than two years. The ophthalmo¬ 
scopic picture as described above is always present, and in addition thereto 
some cases show nystagmus, strabismus, or oculomotor paralysis. The eti¬ 
ology of the disease is unknown, but most of the recorded cases have 
occurred in Jews or Poles. Pathologic studies by Sachs, Hirsch, and 
others have not determined the nature of the disease. Sachs, in his first 
case, found the cerebral fissures uncommonly pronounced, and the cerebrum 
resembled that found in a lower order of development. While the chiasma, 
pons, and medulla and great ganglia were normal, the great pyramidal 
cells were lacking or were markedly degenerated in the cortex. Changes 





PLATS' XIX, 

Diseases of tha Retina, 


Fig, 1,— ilihuminuriG Neuroretinitis in a Child with 
Congenital Syphilis, The lesions in the macular region 
were attributed to syphilis, (Leopold,) 


Fig. 2,—Retinitis Circinata. (Da Schweinttz.) 


M2 




, ■ ■ 






; «•» »J :l < 

' 

r-nul; 

,li ihf t 

‘ 

nett' v • • u ' 

feint*-' 


..XIX 

•BnW^Jd Qiii lr sesEaslEI 

-be wearing of proper 
I‘set'beo 'vu!•••.*■ >n the 




y. (In ffi at ile Amaurotic 
with Symmetrical Changes 

\V;;mi T« 3 t reported the case 

first examined the op hrs 
a hit* plaque, 

•. thus re enabling the opiaha!- 
<1 retinal an ary. Fire momin 

ji-itostr bltsRS & a/ ! *> I ophlC. 

pzt&?Z 't£i£i'3££n. sill ni :.notara • WMWl a The elm- 

,A.l r .*cscI) , etuxfqT 2 of tsix/dWJJs sisw 







*> (is m-huo:* and 

vo .old it - 1 . < ■■ ■ ci ■ the 
by inara-mum Only 

(.&iinlswdc2 t'i) . stsiflaitn attiotiJeH- 4 -.'8• .grit ' ' ' ^ 1 •.»11 < > 

a >d in addi u thereto. 

;r paralysh Foe oti- 
K corded - if-es 1*8 v- 
■ Sachs, Mirseh, find 
. Sachs, n his :ir*t 
and c< ro-bnnn 
While the chiasma, 
■ at pyramidal 
• ortex. Changes 







PLATE 19 










DISEASES OF THE RETINA. 


513 


were also found in the spinal cord and retina. Holden found degeneration 
of the ganglion-cells of the retina. Sachs has recently examined another 
case. This showed some deficiency in the development in the cerebral 
white fibres and degeneration of the pyramidal tracts in the spinal cord. 
While there was an increase in the neuroglia-cells, the most marked change 
was found in the large ganglion-cells of the entire nervous axis. The 
cells showed disintegration, shifting, or entire absence of the nucleus, and 
the formation of pericellular spaces. Sachs regards the changes as due to 
an arrest of development, while Kingdon and Eussell look on them as due to 
a degenerative process. Hirsch regards the disease as an acquired affection 
involving the nerve-cells of the entire system, produced by some kind of 
toxic agent. Treatment of this disease must be wholly symptomatic. 

Retinitis Circinata (Circinate Retinitis).—This rare form of retinitis 
was first accurately described by Fuchs in 1893, who observed it in 12 of 
70,000 patients. It is characterized by the appearance, in the macular 
region, of a circular or oval zone of yellowish-white exudation, which, 
with indented edges and pigmented borders, often resembles a wreath (Fig. 
2, Plate XIX). Often -the macula itself is diseased, showing irregular 
pigment patches resting on areas of yellow exudate. The retinal vessels 
pass over the circinate deposits. The remainder of the fundus is normal. 
Vision is gradually reduced in these cases, and the visual field is slowly 
limited. A central scotoma is present; the light-sense is unaltered; meta- 
morphopsia, night-blindness, and day-blindness are absent. The disease 
is eminently chronic, and the ophthalmoscopic picture may remain un¬ 
changed for years. On the other hand, de Wecker has observed new hemor- 
rhages with the formation of new white spots. In Fridenberg’s case new 
vessels formed in the retina. De Wecker saw circinate retinitis in one 
eye and hemorrhagic retinitis in the other of an aged diabetic subject. 
Vitreous opacities of various sizes, retinal detachment, and thickening of 
the retina at the macular region have been observed in these cases. 

Etiology and Pathology.— The etiology of circinate retinitis is un¬ 
known. The disease seems, however, to depend on arterial sclerosis. 
Syphilis may be an etiologic factor. The age of the accurately recorded 
cases has varied from 6 to 77 years. The disease has been seen more often 
in women than in men. In 5 of the 12 cases observed by Fuchs the 
changes were symmetrical; in 7 only one eye was affected. 

Fuchs regarded the white patches as fibrinous exudates into the deeper 
parts of the retina. De Wecker attributed the changes to fatty degenera¬ 
tion, the result of hemorrhages. Ammann, after having made the ana¬ 
tomic examination of an eye which at one time presented a typical picture 
of retinitis circinata, concluded that the white spots are brought about 
by fat-cell clusters sequent to hemorrhages. 

Diagnosis. —The ophthalmoscopic picture is so typical that the diag¬ 
nosis should not present much difficulty. However, de Wecker has called 
attention to the danger of mistaking this disease, when it occurs in chil- 


33 


51-1 


MODERN OPHTHALMOLOGY. 


dren, for neuroepithelioma of the retina. He cites the case of a girl, 6 
years of age, in whom a confrere removed an eye which for two years had 
presented lesions resembling neuroepithelioma of the retina. Examina¬ 
tion showed the presence of plaques of atrophied chorioid and degenerated 
retina, as well as a small ossifying fibroma. 

Prognosis. —Although the disease is incurable, in none of the re¬ 
corded cases has the patient become entirely blind. 

Treatment. —This must be carried out on general principles, tonics 
or antisyphilitic remedies being used as indicated. Errors of refraction 
should be corrected. 

Retinitis from Exposure to Excessive Light.—Conjunctivitis, kera¬ 
titis, and retinitis may be produced by exposure to excessive light, either 
from looking at the sun (solar retinitis), from reflection from the snow 
(snow-blindness), from the injurious effect of electric light (electric 
ophthalmia), or from a flash of lightning. 

Solar Retinitis.- —Blinding of the retina from looking at the sun 
has occurred in a number of cases, chiefly from the observation of solar 
eclipses. Following the exposure the patient will complain of a central 
scotoma, which may be absolute. Central vision for colors is also defective. 
Distortion of objects is also a symptom. Visual acuity may be slightly 
or greatly reduced. The duration and extent of these symptoms will 
depend upon the length of exposure and the intensity of the sunlight. 
Ophthalmoscopic changes may be absent, or may include loss of the macular 
reflex, the presence of a small spot of an orange color near the fovea, with 
alterations in pigmentation. The prognosis in solar retinitis must be 
guarded. Severe cases do not improve. Swanzy states that hitherto no 
case in which vision was reduced to less than one-third has recovered full 
visual acuity. The treatment will include rest, the wearing of dark glasses, 
the hypodermic injection of strychnia, and the use of the constant galvanic 
current. 

Snow-blindness. —Exposure of the eyes to the reflection from snow 
causes ocular changes, and may lead to permanent blindness. Usually, 
however, the lesions are limited to the conjunctiva and cornea. There is 
intense photophobia, blepharospasm, and sometimes chemosis, together 
with the ordinary evidences of conjunctivitis. The cornea may present 
dendriform ulceration. Some cases complain of the sensation of a foreign 
body in the conjunctiva. Eoyes states that the retina may be anesthetic 
or hyperesthetic. The prognosis is favorable. The treatment includes 
rest, the wearing of smoked glasses, the use of holocain drops, and cold appli¬ 
cations. 

Electric Ophthalmia. —Exposure to flashes of electric light, during 
electric welding or from the short-circuiting of the current, may produce 
conjunctival, corneal, and retinal changes. The same changes may be 
found in electricians who use a strong arc light. In a few minutes, or 
perhaps several hours after exposure, the patient will complain of burning 


DISEASES OF THE RETINA. 


515 


pain in the eyes, photophobia, blepharospasm, swelling of the lids, and 
perhaps reduction in vision. The pupil is strongly contracted. These 
symptoms are followed by a muco-purulent conjunctival discharge. Exam¬ 
ination may show contraction of the field of vision, the presence of a small 
scotoma, congestion of the retinal veins, and slight haziness of the retina. 
Rivers saw a case in which there was exfoliation of the corneal epithelium 
and retinal opacity with great reduction in visual acuity. The patient’s 
face and eyebrows were burned. 

While the prognosis is usually favorable in these cases, in the severer 
types of injury there may be permanent reduction in visual acuity, and 
pain and photophobia may be of long duration. Usually rest, the wearing 
of dark glasses, and the use of atropin will be followed by an early recovery. 
Pain in the acute stage may be relieved by the instillation of holocain and 
the application of cold compresses. 

Punctate Conditions of the Fundus.—Occasionally, in eyes apparently 
normal, minute white or yellow dots are seen, either single or arranged in 
groups. The width of one of these dots usually does not exceed that of 
the retinal vessels. Some of the punctate conditions of the fundus doubt¬ 
less take their origin from the chorioid, while others begin in the retina. 
Although these punctate conditions cannot be properly classified, some 
authors attributing them to the chorioid and others to the retina, they will 
all be considered in this place. According to Frost, they are chiefly: (1) 
Gunn’s dots; (2) metallic dots; (3) isolated dots; (4) retinitis punctata 
albescens; (5) Tay’s chorioiditis; (6) colloid change in the macular 
region (this has been described in Chapter XII) ; (7) diffuse dots resem¬ 
bling Tay’s chorioiditis. 

1. Gunn’s Dots (“Crick’s” Dots). —These are small whitish or yel¬ 
lowish dots which may be single, but generally are found in clusters in the 
region of the yellow spot. They are seen with difficulty, and are found 
chiefly in young subjects. They are without pathologic significance. 

2. Metallic Dots. —These occur singly, and may be present in any 
part of the fundus. They are brilliant, and have been likened to particles 
of mercury. Frost has found them chiefly in cases where the ophthalmo¬ 
scope was used to find the cause of an unexplained amblyopia, but they are 
also seen in normal eyes. They are supposed to be due to an irregularity 
of the retinal surface, producing total reflection, the metallic appearance 
being caused by the image of the mirror of the ophthalmoscope. 

3. Isolated, or Xeuritic, Dots. —Tnese are found in the foveal 
region in cases of neuroretinitis, and are as white as chalk and of irregular 
shape. 

4. Retinitis Punctata Albescens. —Under this name Mooren de¬ 
scribed the case of a man, 30 years of age, whose fundus presented hundreds 
of white spots distributed equally. The spots are small and of white or 
yellow color, without pigment borders. They never coalesce, and are rarely 
found in the foveal region. The disease causes reduction in central vision. 


516 


MODERN OPHTHALMOLOGY. 


while peripheral vision is normal. Night-blindness is absent. The few 
cases which have been studied occurred in young subjects, and. the disease has 
been found in several members of the same family. It is supposed to be 
•either a congenital affection or one that develops in early infancy. 

Nettleship has described a somewhat similar affection in which minute, 
white, round spots w r ere scattered over the fundus and were associated with 
pigment changes at the periphery and with night-blindness. They are 
known as Nettles hip’s dots. They are stationary or slowly progressive. 
Some authors have regarded this condition as a variety of retinitis pig¬ 
mentosa, but this view is generally considered erroneous. 

5. Tay’s Chorioiditis, also known as central senile guttate chorioi¬ 
ditis, or punctate retinitis, includes a group of cases characterized by the 
presence of round, light-colored dots, which are found chiefly in the cen¬ 
tral part of the fundus. The dots are small, their diameter equaling that 
of the primary retinal arteries. They occur chiefly in middle-aged persons. 
When the dots are numerous, this disease causes some loss of vision. 

6. Colloid Change in tile Macular Region. —This condition is 
described in Chapter XII, and is regarded as belonging to chorioidal dis¬ 
eases. 

7. Diffuse Dots resembling Tay’s Chorioiditis. —In this condi¬ 
tion numerous dots, which are not limited to the macular region, are found 
in the eyes of young subjects, and remain for many years without appreci¬ 
able change. In some of the cases, however, night-blindness and some con¬ 
traction of the visual field have been observed. 

Prognosis and Treatment. —The punctate conditions of the fundus 
do not admit of removal. They do not often lead to much loss of vision. 
These cases should receive general attention. Errors of refraction should 
be corrected, if present. It may be advisable to limit the amount of near 
work. 

PURULENT RETINITIS. 

Until recently the possibility of the occurrence of purulent retinitis 
apart from purulent chorioiditis has been denied. Clinically cases of 
purulent retinitis may be divided into four classes: (1) purulent trau¬ 

matic retinitis, (2) purulent secondary (or induced) retinitis, (3) purulent 
metastatic (or embolic) retinitis, and (4) septic retinitis of Roth. 

Purulent Traumatic Retinitis results from infection following per¬ 
forating wounds or the lodgment of foreign bodies. The clinical picture is 
essentially that of suppurative chorioiditis (panophthalmitis). 

Purulent Secondary Retinitis follows upon perforating ulcers of the 
cornea. The clinical picture is that of panophthalmitis. 

Purulent Metastatic, or Embolic, Retinitis may arise in the course of 
any one of many infectious diseases. The symptoms may be acute, resem¬ 
bling those of panophthalmitis, or chronic, resembling pseudo-neuroepi¬ 
thelioma of the retina. The anatomic changes in these affections may 


PLATE 1 XX, 


Diseases of tha itatma, ',;3£f v %r '* 


, vi «•, 


Fig, 1.—Normal Fundus with. Unusual Congenital Pigmentation, 

(Lsopold.) 





Fig. 2,—Posterior Scleral Ectasia In a Highly Myopic (22 DO E/=, 
□ n tils nasal side is ssEn tha " Wsiss raflax.' 1 ( ATsiss.l 






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v • -irailar Wi wnicb mini ie, 





• ■ he fundus ie associate!: with 

and with is i 1 idnc-s. 1 hey are 
are stations dowly progressive, 

condition as of retinitis pig- 

£ . • >* • !i • consider-.i is. 

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ile-aged persons. 
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: i retinitis 
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PLATE 20 














DISEASES OF THE RETINA. 


517 


be gin as a purulent retinitis, a purulent chorioiditis, or as a chorioido- 
retinitis. A form of metastatic retinitis which was first described by Eoth 
as septic retinitis will now be considered. 

Septic Retinitis.—To external examination an eye with septic retinitis 
shows nothing abnormal except possibly conjunctival hemorrhages. The 
dioptric media are clear. Characteristic changes found in the retina, in 
the neighborhood of the papilla and macula, are hemorrhages and white 
spots (Roth’s spots), which vary much in shape and number. There may 
be a single spot or the foci may be numerous. The white spots may exist 
entirely apart from the hemorrhages or may lie within or adjacent to the 
latter. They never assume the stellate figure so often found in the macular 
region in cases of albuminuric retinitis; and, as a rule, they do not tend 
to become larger. They are absent in one-third of the cases, and rarely 
appear alone without hemorrhages. The hemorrhages are found chiefly 
along the large vessels, and seem to be of venous origin. Large preretinal 
effusions of blood are frequently found. Marked signs of inflammation are 
absent, the papilla being generally well defined. The retinal vessels are 
usually not changed in calibre, although the veins may be tortuous. In 
exceptional cases only one eye is involved. One eye may present the picture 
of septic retinitis while the other shows the changes of purulent chorioiditis. 
As a rule, there is no great reduction in visual acuity. In some cases, how¬ 
ever, the general weakness of the patient is so great as to prohibit an ac¬ 
curate examination of vision. Often the advent of the retinal changes can¬ 
not be determined with certainty. Gimurto has observed the disease as 
early as the fifth and as late as the twenty-third day after confinement. 
Septic retinitis has been observed in from 33 to 87 per cent, of cases of 
sepsis. It is found in all forms of sepsis, but is particularly frequent in 
septicemia. The disease runs a slow course^ and, if the patient’s life is 
spared, complete recovery of the eye may occur. Although at the beginning 
the signs of metastatic chorioiditis are similar to those of septic retinitis, a 
differentiation can soon be made. Metastatic chorioiditis runs a rapid and 
destructive course with marked inflammatory symptoms. On the contrary, 
septic retinitis presents no inflammatory symptoms. 

Diagnosis.— The diagnosis of septic retinitis must rest not alone on 
the ophthalmoscopic changes, but largely on the general history of the 
patient. Similar retinal changes, particularly hemorrhages, are found in 
many general diseases. 

Treatment must be directed to the removal of the cause. Tonic and 
supportive measures will be required. 


RETINAL SCLEROSES. 

Retinitis Proliferans (Proliferating Retinitis; Hyperplastic Prolifer¬ 
ating Retinitis).—In this disease numerous bluish-white or gray masses of 
connective tissue develop in the retina and extend into the vitreous humor. 


518 


MODERN OPHTHALMOLOGY. 


In a strict sense the affection is not a retinitis, but a proliferation of the 
connective tissue of the retina. The new tissue obscures the optic disc 
and often is disposed in interlacing bands. The cause is to be found in 
repeated and extensive hemorrhages into the retina and vitreous humor, the 
masses of unabsorbed blood producing atrophy by pressing on the retina 
and causing proliferation of connective tissue. The masses of newly formed 
tissue may follow the general course of the retinal vessels, some of which 
lie under and others over the mass. There is often a development of new 
vessels in these cases. 

Etiology and Treatment. —The etiology of proliferating retinitis is 
unknown. Trauma and syphilis are supposed factors. The disease is rarely 
seen. Schobl observed 2 cases in about 60,000 patients. The prognosis is 
unfavorable, blindness being the ultimate result. Treatment includes the 
use of mercury and iodid of potassium by the mouth or mercury by inunc¬ 
tion. 



Fig. 330. —Proliferating retinitis. (Jaeger.) 


Striate Retinitis (Retinitis Striata; Chorioidoretinitis Striata). —In this 

condition the retina shows yellowish-white or grayish lines which may run 
in almost any direction, but often pass front the periphery toward the disc. 
The lines lie beneath the retinal vessels and frequently are branched. They 
are sometimes found in spontaneously cured cases of retinal detachment. 
Their cause is not known. Caspar considers the disease the final stage of 
reattached retinae, while Holden regards it as due to changes following 
retinal hemorrhages. Vision usually is much reduced in these cases. The 
condition does not admit of treatment. 

Pigment Streaks on the Fundus (Angioid Streaks). —A few cases are 
recorded in ophthalmic literature in which the fundus presented long, irregu¬ 
lar pigment streaks of a red-brown color, lying beneath the retinal vessels, 
varying much in size and ramifications, and in their course resembling a 
S) stem of obliterated blood-vessels. The strias are of varying diameter, pre- 



DISEASES OF THE RETINA. 


519 


senting irregular borders and bending sharply. In the cases thus far re¬ 
ported both eyes have been affected. While the disease has been known to 
follow an injury, in several cases there was no history of trauma. It seems 
reasonable to attribute the angioid condition to retinal hemorrhages, cases 
having been observed by Pflange, Knapp, de Schweinitz, and Holden. 
Pflange states that hyperplastic changes occur in Muller’s fibres. Vision 
may be unaffected, or may be considerably reduced in this disease. There is 
no known method of treatment of avail in these cases. 

Pigmentary Degeneration of the Retina (Retinitis Pigmentosa; Pig¬ 
mented Retina and Chorioiditis). —By this term is meant a progressive 
bilateral disease of the retina, leading to atrophy and blindness, and char¬ 
acterized by the presence of pigment collections in the superficial retinal 
layers, contraction of the blood-vessels, and atrophy of the optic nerve. 

Etiology. —The disease is found in from 5 to 10 per cent, of deaf- 
mutes. It is sometimes attributed to consanguinity in the parents. The 
influence of consanguinity has been overestimated. Macnamara has shown 
that the disease is not infrequent among the Hindoos, whose religion pro¬ 
hibits intermarriage. It is also hereditary. It is not infrequent in idiots, 
in epileptics, in the victims of hereditary syphilis, and in families subject to 
nervous diseases. In many cases, however, the cause cannot be determined. 
The disease is either congenital or begins early in childhood, although the 
pigmentation is probably never present at birth. Retinitis pigmentosa is 
said by Leber to be more frequent in men than in women in the proportion of 
about 5 to 2. Other congenital anomalies are not infrequently present in 
cases of pigmented retina. 

Symptoms. —The subjective signs of this disease are (1) night-blind¬ 
ness, (2) loss of visual acuity, and (3) contraction of the field of vision. 
The most noticeable subjective symptom is night-blindness: i.e., visual 
acuity is disproportionately lowered under reduced illumination. Often a 
patient who is unconscious of visual defect by daylight must be led at dusk 
or on entering a dimly lighted room. Night-blindness may be absent, and 
in rare cases, in which there is retinal hyperesthesia, vision will be best in 
reduced illumination. Central vision may remain practically normal for a 
long time, yet perimetric examination will show there is reduction of the 
field. Usually there is reduction in central vision in proportion to the con¬ 
traction of the field. In exceptional instances good central vision is re¬ 
tained in the presence of great narrowing of the field. This contraction 
leads to loss of orientation. The patient sees as through a tube and often 
knocks against objects. The constant bowing of the head is characteristic. 
Occasionally color-blindness exists in these cases. 

The ophthalmoscopic signs of pigmentary degeneration of the retina 
include changes in the vessels, in the optic disc, and in the retina. The ves¬ 
sels are contracted and their number is diminished. Their walls are thick¬ 
ened, producing a corresponding reduction in their lumen. Often they are 
so small as to resemble mere threads. The optic papilla is of a creamy- 


520 


MODERN OPHTHALMOLOGY. 


white color, usually not the dead white of atrophy. The edges of the nerve 
are generally ill defined and bordered with pigment, but the presence of 
pigment-spots on the nerve-head is very uncommon. The lamina cribrosa 
is usually hidden from view, and the whole disc looks waxy or transparent. 
The most striking of the ophthalmoscopic appearances is the presence of 
irregular pigment-spots, which are most numerous at the periphery and 
resemble bone-corpuscles in shape. They are usually more abundant on the 
temporal than on the nasal side of the fundus. Often the pigmentation is 
most abundant along the course of the larger vessels. Early in the disease 
the pigment-spots are situated in the far periphery, but as time passes they 
encroach upon the posterior pole. As the process extends the retinal pig¬ 
ment layer becomes decolorized, thus permitting a view of the chorioidal 
vessels and giving the fundus a peculiar “wainscoted” appearance (Fig. 2, 
Plate XXI). Pari passu with the growth of the stellate pigment r spots 
atrophy of the retina and disc become manifest. Vitreous opacities are 
uncommon in this disease. Posterior polar cataract is occasionally seen, but 
less frequently than in chorioiditis. 

Diagnosis.— In typical cases diagnosis is not difficult. The pigment- 
spots do not always resemble bone-corpuscles, but may be rounded or irregu¬ 
lar like the pigment collections found in chorioiditis. That the pigment is 
in the retina is determined by the fact that the spots cover the retinal vessels. 
In the pigment accumulations of chorioiditis the retinal vessels can be seen 
crossing the spots. Atypical cases of retinal disease have been described 
which present all of the subjective and objective signs of retinitis pig¬ 
mentosa except that the pigment-spots are absent. A few cases of unilateral 
retinitis pigmentosa have been described. Exceptionally the pigment-spots 
involve the macula, while none are found in the periphery of the fundus. A 
few cases have been recorded of glaucoma in eyes with retinitis pigmentosa. 
Blessig has reported the histories of nine brothers and sisters in whom these 
diseases alternated. 

Pathology.-— The changes are: an atrophy of the nervous structures 
of the retina, the nerve-fibre layer usually remaining. The supporting con¬ 
nective tissue becomes hyperplastic. In places the pigment epithelium 
atrophies; in others, it proliferates, invading all layers of the retina, espe¬ 
cially the perivascular sheaths. Pigment granules may be seen scattered 
in the retina and are sometimes found occluding the lumen of a small 
sclerosed vessel. Where there is an atrophic area in the pigment layer, and 
sclerosis of the chorioidal vessels is present, the retina will become adherent 
to the chorioid. Drusen formations are a frequent accompaniment. An- 
giosclerosis is more pronounced in the arteries than in the veins, the smaller 
vessels often being occluded by hypertrophy of the vessel-walls, many of 
which show hvalin degeneration. 

Prognosis. —The prognosis of this form of retinal disease is unfavor¬ 
able, most of the cases ending in blindness by the time middle life is reached. 
While total blindness is not the rule, vision is so much reduced that the 


DISEASES OF THE RETINA. 


521 


patient needs assistance in getting about. Often, however, the disease re¬ 
mains stationary for long periods. 

Treatment. —There is no cure for this disease. The best results of 
treatment are obtained in the form which is caused by acquired syphilis. 
In all cases of retinitis pigmentosa the eyes should be used in moderation and 
should be protected from excessive light. Errors of refraction should be 
carefully corrected. The frequent use of weak miotics, the internal or hypo¬ 
dermic administration of strychnia, and the employment of mercuric bi- 
chlorid are among the proposed remedies. Electricity in the form of the 
galvanic current applied to the eyeball has seemingly produced good results 
in some cases. 


INJURIES OF THE RETINA. 

Penetrating wounds of the eye having been considered elsewhere 
(Chapter IX), in this place the effect of concussion injuries of the retina 
will be discussed. Such injuries may cause edematous swelling and opacity, 
hemorrhage, detachment, rupture, pigmentation, or traumatic anesthesia of 
the retina. 

Traumatic Retinitis (“Commotio Retinae”; Edematous Swelling of the 
Retina; Concussion of the Retina).—Blows on the eye may be followed by 
edematous swelling and opacity of the retina, the change being situated 
generally in a part of the retina opposite to the point of impact. There is 
marked contraction of the pupil, which dilates imperfectly to atropin. 
There is some episcleral injection and reduction in the acuity of vision. 
The tension is normal, as a rule. Stephenson, however, has reported a case 
of concussion of the retina with minus tension. Ophthalmoscopic examina¬ 
tion made an hour or two after the injury will show a grayish-white or 
milky-white cloudiness existing in disseminated spots and not involving the 
blood-vessels. Soon the spots may coalesce and the whole fundus may be 
involved. In from twenty-four to thirty-six hours the process is fully devel¬ 
oped. Then it begins to decline, the fundus-reflex again becomes visible, 
and in a few days the eye is of normal appearance. In rare instances a 
system of fine radiating lines will, be found around the yellow spot. The 
retina is not thrown into folds, and this fact serves to differentiate commotio 
retinas from retinal detachment. The prognosis is favorable. There may 
be coincident retinal hemorrhages, spasm of the ciliary muscle, and tran¬ 
sient astigmatism. The treatment will include rest, the use of atropin 
drops, and the wearing of smoked glasses: 

Retinal Hemorrhage from Trauma is easily recognized ophthalmo- 
scopically by the presence of an elongated clot and by the loss in the con¬ 
tinuity of the vessel. The treatment will include rest and atropin. 

Traumatic Detachment of the Retina is of rare occurrence. It will 
be mentioned under another head (page 522). 

Rupture of the Retina, apart from the existence of laceration of the 
other ocular tissues, is a rare condition. The rent may occur at any part 


522 


MODERN OPHTHALMOLOGY. 


of the tissue, although the periphery and posterior poles are favorite 
sites. Noyes has seen a loose, tongue-like piece of retina torn up and 
exposing the chorioidal vessels. Aside from rest there is no particular 
treatment for the condition. 

Pigmentation of the Retina following Trauma is not infrequently 

observed as a result of concussion injuries. 

Traumatic Anesthesia of the Retina. —This term has been applied by 
Leber to cases in which reduction in visual acuity and contraction of the 
field, without discoverable ophthalmoscopic signs, followed trauma. The 
condition may continue for many weeks. 

Traumatic Perforations of the Macula Lutea (Chorioidal Craters; 
“Holes” in the Macula). —As a result of concussion injuries, a peculiar 
ophthalmoscopic picture is sometimes found in the macula. It consists 
of a circular red disc or “hole,” which is from one-third to one-half the 
diameter of the papilla, through which the uncovered chorioid is visible. 
Its depth, according to Ogilvie, is about one-half millimetre. Unlike 
chorioidal diseases, in this condition alterations in the pigment epithelium 
and chorioid are absent. The condition is permanent. Vision is not 
greatly disturbed unless a detachment of the retina coexists. A central 
scotoma may be present. The condition does not admit of treatment. 

DETACHMENT OF THE RETINA. 

Separation of the retina from the underlying chorioid is one of the 
most serious of ocular diseases. 

Etiology. —Detachment of the retina was found by Galezowski in 5 / 10 
of 1 per cent, of ophthalmic cases. Men are affected much more frequently 
than women. The disease is most frequent between the forty-fifth and 
sixtieth years. It is rare in childhood and youth, and exceptionally has been 
observed as a congenital condition. The idiopathic cases may be attributed 
to numerous causes, as excessive exertion in lifting, bicycling, stooping, 
coughing, sneezing, vomiting, childbirth, anger, fear, etc. The traumatic 
cases are either primary or secondary. Among the causes of the former are 
contusions or wounds of the globe, extraction of cataract, iridectomy, etc., 
especially in eyes whose chorioidal and retinal vessels are degenerated. 
The secondary traumatic cases are those in which, following injuries, inflam¬ 
matory products in the chorioid undergo shrinking. Owing to the attendant 
stretching of the chorioid and sclera, retinal detachment is not uncommon 
in myopic eyes. In the production of idiopathic retinal detachment no 
other one factor is so potent as is myopia. The statistics of Rydel, Walter, 
Hortsmann, and Galezowski show myopic refraction in from 48 to 90 per 
cent, of cases of retinal detachment. This percentage, however correct it 
may be for Europe, is much too high for the United States. Detachment 
may follow iridocyclitis and chorioiditis. It rarely follows albuminuric and 
other forms of retinitis. It may occur in purulent chorioidoretinitis, and 
is an expected condition in intra-ocular tumors and cysticercus. 


PLATE XXI, 











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PLATE 21 











DISEASES OF THE RETINA. 


523 


Pathology.—Leber noticed that in idiopathic detachment a perforation 
frequently exists in the floating .retina. From ophthalmoscopic findings, 
pathologic studies, and experiments made on the lower animals, he an¬ 
nounced the theory that retinal detachment in non-traumatic cases is due 
to shrinking of a diseased vitreous humor. This shrinking causes a rent in 
the retina, and the fluid, which is always found behind the vitreous humor 
in cases of detachment of this body, jjasses through the tear in the retina 
and serves by gravity further to increase the separation of this membrane 
from the chorioid. Leber’s view has been confirmed by Nordensen, who, 
in 119 cases of detachment, found laceration of the retina in 49 (38.6 per 
cent.). The latter authority holds that the primary disease is located in the 
ciliary body and chorioid; this is followed by fibrillary degeneration and 
subsequent contraction of the vitreous; the vitreous becomes adherent to 
the retina, and in contracting pulls the retina from the chorioid. The 
separation of the retina from the chorioid may begin at any part, but 
probably commences most frequently in some part of the upper half. At 
the ora serrata and optic disc there is no separation except in rare cases of 
severe trauma. Thus, the detachment, when complete, assumes a funnel 
shape; however, the area, depth, and situation of the detachment are sub¬ 
ject to great variation. The pigment layer always remains on the chorioid. 

In opposition to the views of Leber and Nordensen, Raehlmann has 
advanced the “diffusion theory,” which ascribes retinal detachment to exu¬ 
dation from the chorioidal vessels of a fluid more albuminous than the 
vitreous humor. He contends that diffusion occurs through the retina, the 
ingredients of the vitreous humor collecting behind the retina and lifting it 
up. The diffusion theory has recently found confirmation in experiments 
made on rabbits by Sinclair. Which of these theories is correct must be 
determined by future investigations. 

Old cases of retinal detachment often show cataract, and the opaque 
lens frequently undergoes calcareous degeneration. The tension of the eye 
is usually minus. Both eyes may be involved in retinal detachment; in 
the majority of cases but one eye is affected. 

Symptoms.—Prodromal symptoms of retinal detachment are periodical 
dimness of vision, photopsise, and the appearance of sparks, dust, or soot 
before the eyes. The subjective signs include a limitation of the field of 
vision, the appearance of a cloud or of floating specks before the eye, etc. 
Patients often complain that they can see only a part of an object. So 
long as the macular region is not involved central vision will be good. 
Generally patients with retinal detachment will notice sudden loss of vision, 
but the detached retina may functionate for a time, producing vertigo and 
metamorphopsia. In uncomplicated cases there is no pain. 

Externally there are no noticeable signs. The anterior chamber may 
appear deeper than normal. The tension is usually minus. Ophthalmo¬ 
scopic examination shows the normal fundus-reflex lost wholly or in part, 
the retina in its detached portion appearing as a gray, vibrating, rounded 


524 


MODERN OPHTHALMOLOGY. 


membrane on whose folds retinal vessels are visible. The vessels are small 
and of dark color, having lost their central light-streak. The optical con¬ 
dition of the detached retina is that of a highly hypermetropic eye, a strong 
convex lens being required for the study of its details. The irregular folds 
of the detachment show white lines,—produced b}^ reflection from the apices 
of the folds,—while the furrows appear dark (Fig. 1, Plate XXI). The 
ophthalmoscopic picture is so striking that when once seen it should not 
be forgotten. Failure to find an old detachment can occur only through 
opacity of the cornea or lens, or by neglect to examine the periphery of the 
fundus. Often the detached and floating retina can he seen by ordinary 
focal illumination. It may be seen to undulate in response to the ocular 
movements. 

Diagnosis. —While recognition of the presence of a detachment of the 
retina is ordinarily easy, in exceptional instances it is difficult, espe¬ 
cially where the detached portion remains unchanged in color. This 
occurs particularly in recent cases, in young persons, where the fluid 
behind the retina is clear. In such cases a diagnosis will rest on the 
determination whether the vessels are smaller, more tortuous, and darker 
than elsewhere, and on the finding of differences in the refraction of dif¬ 
ferent parts of the fundus. By direct ophthalmoscopy the detached portion 
can be clearly seen only through a weaker concave or a stronger convex 
glass than is required for the remainder of the fundus. In indirect ophthal¬ 
moscopy the surgeon will need to withdraw his head and the interposed 
convex lens more or less. Parallactic movement of the vessels over the 
fundus is often observed in detachment. In many instances careful exam¬ 
ination by the direct method will show a tear in the detached retina through 
which the chorioid is visible. A flat detachment— i.e., one with a thin 
layer of fluid beneath it—may escape detection. Here the red color of the 
fundus is intermerged with a grayish cloudiness of the affected area and 
the vessels are unduly black and tortuous. In old cases of detachment, 
where the retina is atrophic and has again become clear, the chief diagnostic 
sign will be the vascular changes mentioned above. 

The diagnosis between tumor of the chorioid and simple detachment 
of the retina has been considered on page 416. Subretinal cysticercus has 
been mentioned elsewhere in this chapter. Edema of the retina may be 
mistaken for detachment. In the former condition the fundus presents a 
more uniform appearance and the retina is not folded. Eetinitis proliferans 
is often associated with retinal detachment. 

Prognosis.— The prognosis in detachment of the retina is very bad. 
Only in rare instances is there a permanent reattachment, spontaneously 
occurring or following treatment. According to Schobl, the most favorable 
cases are those in which detachment occurs in the albuminuric retinitis of 
pregnancy, in chorioiditis, and in those which follow diseases of the orbit 
and traumatism. In detachment following myopia the prognosis is un¬ 
favorable. 


DISEASES OF THE RETINA. 


525 


Treatment.— The treatment of retinal detachment is an unsatisfactory 
—in fact, almost hopeless—task. While in a few rare instances the retina 
has become reattached spontaneously, and a few recoveries have followed 
prolonged rest on the back, with hypodermic injections of pilocarpin and 
the administration of saline purgatives, and some cures have followed the 
internal use of mercury, iodid of potassium, and salicylic acid, the majority 
of successful results thus far reported have been attributed to surgical inter¬ 
vention. Surgical intervention, proposed by Sichel in 1859, has assumed 
numerous forms: simple puncture of the sclera and chorioid (Sichel), dis¬ 
cission of the retina (von Graefe), drainage by a fine gold wire passed 
through the sclera and chorioid (Grizon, de Wecker), stitching the retina 
to the chorioid by means of catgut (Galezowski), dislaccration with two 
needles (Bowman), iridectomy (Galezowski and others), injection of iodin 
into the subretinal space (Galezowski, Gelpke, Scholer), electrolysis (Gillet 
de Grandmont), cutting of vitreous bands and transfixion of the eyeball 
(Deutschmann, Jaencke), injection of a 3.5-per-cent, strength solution of 
gelatin in a physiologic salt solution between the sclera and capsule of 
Tenon (de Wecker), puncture of the eyeball with the galvanocautery 
(Galezowski, Abadie), injection of normal salt solution into the vitreous 
after evacuation of subretinal fluid (Walker), and injection of air into 
the vitreous (Jensen). Most of these procedures should be ruled out 
of the domain of modern ophthalmology. All are dangerous to the integ¬ 
rity of the globe, and one of them—intra-ocular injection of iodin has 

been followed by meningitis and death. 

Of the surgical measures mentioned above, the most promising are 
simple puncture with a cataract-knife, puncture with the galvanocautery, 
and subconjunctival injections of salt solution, The last of these pio- 
cedures has the advantage of innocuousness. Starkle, of Basel, has reported 
23 comparatively recent cases of detachment treated by injections of salt 
solution, the strength being increased from 2 to 10 per cent. He reports 
improvement in 21 cases and complete reattachment in 3. Dor, of Lyons, 
claims 14 complete recoveries in 21 cases. He used subconjunctival injec¬ 
tions of 20-per-cent, strength salt solution, leeches, and punctate cauteriza¬ 
tions of the sclera, each of these procedures being used once weekly in rota¬ 
tion. Stillson, of Indianapolis, has saved 4 out of 5 cases of detachment 
treated by the galvanocautery. Winselmann has had 3 cures following 
subconjunctival injections and the use of compress bandages. M bile these 
reports are highly encouraging, it must be remarked that in some of them 
not sufficient time has elapsed to enable judgment to be passed upon the 
value of the treatment. Sutphen, however, cured a case of bilateral detach¬ 
ment by scleral puncture and eleven years later vision was normal. Hann 
and Ivnaggs have observed a case of symmetrical retinal detachment occur¬ 
ring during labor and associated with albuminuria, with complete recovery. 
While restoration of vision is more likely to occur in recent than in old 
cases, some remarkable cases of reattachment are reported. Thus, Dor is 


526 


MODERN OPHTHALMOLOGY. 


said to have observed reattachment with restoration of vision after seven 
years, and Wolfe, of Melbourne, had a successful result after three years. 
Detachment caused by cysticercus and by intra-ocular growths will call for 
treatment proper for these conditions, viz.: removal of cysticercus and 
enucleation in tumor. Finally, it must be stated that retinal detachment 
is only a symptom, and search should be made for the underlying cause. 


FUNCTIONAL DISEASES OF THE RETINA. 

Hyperesthesia of the Retina (Irritation of the Retina). —This term is 

applied to a condition in which, without demonstrable ophthalmoscopic 
lesions, the retina is unduly sensitive to light. Photophobia, neuralgia, 
blepharospasm, lacrimation, and inability to use the eyes for moderate 
periods are prominent symptoms. In pronounced cases there is pain in the 
temples or over the brow; quivering and unsteadiness in vision may be 
noticed; nausea anti dizziness may be present; and, in short, the condition 
simulates asthenopia from an error of refraction. Yet these symptoms 
sometimes occur in eyes with normal refraction (Loring). Ophthalmo¬ 
scopic examination may show veiling of the optic disc, particularly on its 
nasal side; slight redness of the nerve-head; a striate condition of the retinal 
fibres passing from the disc; and the whole fundus may appear indistinct. 
The chorioid may present evidences of hyperemia (page 420). 

Etiology. —Hyperesthesia of the retina may be a forerunner of serious 
organic optic-nerve disease (Loring). Errors of refraction or of muscle- 
balance and disease of the nasopharynx are causes. 

Diagnosis, Prognosis, and Treatment. —The diagnosis of retinal 
hyperesthesia must be determined by exclusion. The prognosis should be 
guarded. While the affection does not lead to blindness, the inability to 
use the eyes may continue for a long period in spite of careful treatment. 
In the treatment the surgeon should investigate the general condition of 
the patient most thoroughly. The blood and urine should be examined. 
The condition of the nose, throat, lungs, etc., as well as the state of the re¬ 
fraction and muscle-balance should be determined. Any departure from 
the normal should be corrected. Tonics, alteratives, and strychnia may be 
of benefit in some cases, while others may respond to electricity. Rest, 
change of scene and of occupation should be considered in intractable cases. 

Anesthesia of the Retina (Neurasthenic Asthenopia; Hysteric Am¬ 
blyopia). —This term is applied to a complicated neurosis in which re¬ 
duction in acuity of vision and contraction of the visual field are present in 
connection with functional disturbances in other parts of the body, without 
the existence of ophthalmoscopic signs of disease. 

Etiology.— The causes of anesthesia of the retina are numerous, 
and include overwork of the eyes or body, lesions of the genito-urinary 
organs, traumatism, conjunctivitis, errors of refraction or of muscle-balance, 
intranasal disease, impaired nutrition, prolonged exposure to cold, etc. 


DISEASES OF THE RETINA. 


52? 


Symptoms. —Among the prominent symptoms are inability to use the 
eyes for ordinary work, irregular variations in the acuity of vision, sudden 
obscuration of vision, hallucinations of sight, a feeling of heaviness or weari¬ 
ness in the eyes and eyelids, a lack of fixity of the memory-images of 
observed objects, photophobia, and a diminution or an absence of these 
symptoms at dusk or on wearing dark glasses. 

The perimetric symptoms, however, are of much more value, and in¬ 
clude concentric contraction of the field of vision and rapidly occurring 
variations in the extent and shape of the fields. If two or three perimetric 
examinations are made in rapid succession, these variations will become 
apparent. They include contraction or overlapping of the field or reversal 
of the color-fields. The field may even be hemianopic or defective in sectors, 
or an oscillating field may be found in which an object recognized at one 
meridian is soon lost and again regained. A relative central scotoma is not 
uncommon. 

Diagnosis. —The diagnosis of retinal anesthesia must be made by ex¬ 
clusion. Careful ophthalmoscopic examination will fail to show fundus 
changes. The fields of vision are practically typical of the condition. The 
loss or obscuration of vision appears and disappears suddenly. It is usually 
greatest when sympathizing friends are present. 

Prognosis. —The affection is not serious, but may be of long duration. 

Treatment. —The treatment of retinal anesthesia must be conducted 
on a broad basis. Not only should attention be given to the correction of 
any ocular abnormality present, but the dietetic, hygienic, mental, and 
moral conditions should be considered. The rest cure, change of scene and 
surroundings, exercise, tonics, sea-bathing, and outdoor life are among the 
measures from which benefit may be expected. The use of dark glasses 
will be advisable, although some patients become too dependent upon them. 

Tuberculosis of the Retina. —Few cases of this disease have been re¬ 
ported. In that observed by O’Sullivan and Story a woman, aged 21 years, 
complained of loss of vision in the right eye. Ophthalmoscopic examination 
showed an intense papillitis, the swelling being of a brilliant whiteness. 
Small, white spots were present in the macular region. Two months later 
vision was reduced to perception of light, pericorneal injection and discolora¬ 
tion of the iris were present, but the tension was normal. The eye was 
enucleated, and presented a tumor around the optic-nerve head. Micro¬ 
scopic examination showed typical tubercular structure. The tumor was 
separated from the chorioid by a coagulum. 


CHAPTER XVI. 


DISEASES OF THE OPTIC NERVE. 

The optic nerve is liable to congenital malformations, tumors, inflam' 
mations, injuries, and functional disturbances. 


CONGENITAL ANOMALIES. 

Absence (Aplasia) of the Optic Nerve has been observed in a few in¬ 
stances, chiefly cases of anophthalmos. The nerve may be represented by a 
fibrous cord, which is destitute of nerve-fibres. Barelv its absence exists 
with the absence of the chiasma and with various anomalies of the nerve- 
centres. 

Atrophy of the Nerve is a rare congenital condition, and is found in 
cases of microphthalmos and in anophthalmos. Congenital atrophy, the 
other portions of the globe being normal, has been described. 

Coloboma of the Optic Nerve.—In ophthalmic literature about fifty 
cases are recorded of coloboma of the optic disc, existing either alone or 
associated with coloboma of the sheath of the nerve. The condition, which 
was for a long time confounded with the posterior sclerochorioiditis of 
myopia, is characterized ophthalmoscopicallv by an apparent increase in the 
diameters of the optic disc and by the presence of an excavation (Fig. 331). 
The excavation may surround the disc, but in the majority of cases it 
is situated interiorly, which differentiates it from the external (tem¬ 
poral) staphyloma of myopia. The coloboma is generally of a uniformly 
white or bluish-white color, and sometimes is bordered with pigment. 
It may assume a funnel shape. In such a case, observed by Bandall, 
the greater part of the disc presented a depth of 6 dioptres, while a cir¬ 
cular pit in the lower part of the disc was 4 dioptres deeper. The ves¬ 
sels may emerge in the centre of the disc, but usually they appear at the 
periphery of the excavation. Coloboma of the disc and sheath may exist 
separately, together, or in conjunction with coloboma of the chorioid. 
The position and shape of the coloboma, the irregular position of the vessels, 
and the frequent existence of other anomalies will serve to distinguish 
coloboma of the optic nerve from posterior scleral staphyloma. The 
anomalv is attributed to non-closure of the cleft, which in earlv fetal life 
is found in the lower part of the nerve. The so-called inferior conus, a 
condition in which the nerve-head does not fit accurately into the chorioidal 
aperture, has been found by Wollenberg and Vossius in about 1 per cent, 
of ophthalmic patients. According to the researches of Jaeger, Schnabel, 
(528) 


DISEASES OF THE OPTIC NERVE. 


529 


and Euchs, it is to be regarded as a rudimentary coloboma of the sheath 
of the optic nerve or of the adjacent chorioid. 

Eyes showing optic-nerve coloboma often present other defects (mi¬ 
crophthalmos, lenticular opacities, lenticonus, persistent hyaloid artery, 
retinitis pigmentosa, persistent nerve-fibres in the retina, astigmatism, 
defects in the visual field, etc.). Treatment is limited to the correction of 
errors of refraction. 



Fig. 331.—Coloboma of the optic nerve and chorioid. (Posey.) 


Congenital Cupping and other Conditions of the Disc.— r l hese condi¬ 
tions are of rare occurrence. Congenital cupping of the disc may show an 
unusually deep physiologic excavation, suggestive of the glaucomatous cup. 
The fact that the cup does not extend to the edge of the disc, and the absence 
of arterial pulsation, will serve to distinguish this congenital abnormality 
from glaucoma. Pigment patches on the disc are often seen, the pigment 
of the chorioid being continued into the lamina cribrosa. This congenital 


34 




530 


MODERN OPHTHALMOLOGY. 


condition should not be confounded with pigment-spots acquired after hemor¬ 
rhage. A black area of pigment with serrated edges, occupying the centre 
of the nerve-head, was found by Liebreich in cyanosis oculi —a condition in 
which the pigmentation of the whole fundus is markedly increased, the 
macular region appearing almost black. 

The congenital condition known as spurious optic neuritis is men¬ 
tioned elsewhere in this chapter (page 541). 


TUMORS. 

Primary Intradural Tumors of the Optic Nerve (Fibromatosis Nervi 
Optici—Byers).—The true, or intradural, primary tumors of the optic nerve 
are rare, Byers (1901) having been able to collect accounts of only 102 
cases in the literature; 

Etiology. —Age is a factor in this disease. Of 85 cases collected by 
Byers in which the age was recorded, 67 occurred at fifteen years or younger; 
32 cases occurred between the first and fifth years. The disease is found 
more frequently in females than in males, and more often on the left side. 
Trauma and febrile disturbance or infectious disease are apparent etiologic 
factors. 

Symptoms.' —The most striking symptom is the gradual development of 
painless exophthalmos, the direction of the proptosis being in the majority 
of cases directly forward, or forward, downward, and outward, although it 
may be forward and upward, outward, or inward. Exceptionally the ex¬ 
ophthalmos has developed rapidly. The patient may complain of pain 
throughout the distribution of the fifth nerve. The proptosis is attributed 
chiefly to the direct influence of the tumor, although, in some instances, it 
is influenced by the state of the orbital blood-vessels, or by stasis in Tenon’s 
space and in the supravaginal lymph-space of the nerve. 

A second symptom of importance is the early and great loss of vision. 
In 69 per cent, of the cases tabulated by Byers vision was absolutely lost 
in the affected eye at the time of first examination. Variations in visual 
acuity have been recorded in individual cases. 

The ophthalmoscopic changes are various. Of 82 cases in which men¬ 
tion is made of the condition of the fundus, 3 showed simple atrophy of the 
optic nerve, 34 presented optic neuritis, and 36 gave evidence of post-neuritic 
atrophy. In 3 cases the fundus was normal. Among the ophthalmoscopic 
appearances rarely found in primary tumors of the nerve are dilation of 
the retinal veins, partial detachment of the retina, and hemorrhages. The 
majority of patients present no lesion of the orbital muscles, although 
strabismus sometimes is noted, and, indeed, may precede the exophthalmos. 
In some cases palpation will enable the surgeon to determine the presence 
of an intra-orbital growth which is not adherent to the orbital walls. The 
general appearance of the patient does not usually differ from the normal; 
but cerebral symptoms—such as convulsions and epileptic seizures—have 


DISEASES OF THE OPTIC NERVE. 


531 


been noted in rare instances. Dizziness, vertigo, and tinnitus aurium are 
rarely present. As regards the eyeball, tension is usually normal, but may 
be minus or plus. A characteristic symptom is antero-posterior flattening 
of the globe from pressure of the tumor posteriorly, causing the eye to 
become hypermetropic. Lagophthalmos and keratitis have also been found 
present. 

Pathology. —The dural covering of the nerve forms a capsule, one- 
half to one millimetre in thickness, which envelops the tumor. The growth 
may vary in size from a slight enlargement of the optic nerve to a mass the 
dimensions of a goose-egg. Usually a piece of normal nerve separates the 
tumor from the eyeball. In the opposite direction, however, the growth 
may extend up to or through the optic foramen, and involve the brain. The 
microscopic diagnosis of the reported cases shows a large number of dif¬ 
ferent terms, the majority being set down as myxosarcomata, myxomata, 
myxofibromata, or sarcomata. Since tumors of the optic nerve show, in one 
and the same specimen, several phases of developing connective tissue, Byers 
considers that they should all be classed as fibromata. When cerebral symp¬ 
toms occur, and death ensues after removal of a primary tumor of the optic 
nerve, the result is to be attributed, not to recurrence, but to the continued 
growth of the intracranial portion of the neoplasm, which could not be 
removed by operation. 

Diagnosis and Prognosis. —The symptoms enumerated above will 
enable the surgeon to assert the presence of a growth connected with the 
optic nerve, but it is doubtful if intradural growths can always be differ¬ 
entiated from extradural ones. The prognosis is serious. The eye in many 
instances must be sacrificed, and in some cases there is a continued develop¬ 
ment of the intracranial portion of the tumor, which could not be removed 
at the time of operation. Where the tumor is located chiefly in the anterior 
portion of the optic nerve, total removal is feasible. 

Treatment. —Since the condition rarely shows a tendency toward 
malignancy, and because in most cases the neoplasm does not encroach on 
the globe, modern ophthalmologists have sought to extirpate the growth 
while preserving the eyeball. Scarpa in 1816, Critchett in 1852, and Knapp 
in 1874 were the first to follow this method. Knapp, in operating on an 
extradural tumor, made his opening through the conjunctiva and Tenon’s 
capsule between the superior and internal recti, separated the optic nerve 
from the globe, then cut the nerve at the optic foramen, and pried the 
tumor out with scissors. Gruening, of New York, was the first to remove 
a primary intradural tumor of the nerve with preservation of the globe. In 
recent years Kronlein has devised an operation which is suitable for these 
cases (see page 652). 

Primary Extradural Tumors of the Optic Nerve are ophthalmic curios¬ 
ities, 18 cases having been recorded. Of these 8 were endotheliomata. 
This type of tumor generally begins before the age of ten years. Exophthal¬ 
mos is the most prominent symptom. The loss of vision is slower than 


53.2 


MODERN OPHTHALMOLOGY. 


with intradural tumors. The growth increases slowly, is of relatively low 
malignancy, and causes neither metastasis nor glandular involvement. In 
none of the recorded cases was the globe invaded (Parsons). The treat¬ 
ment is removal. 

Hyalin Bodies in the Nerve-head (Colloid Bodies; Verrucosities; Dru- 
senbildungen).—A rare condition is the presence in the optic-nerve head of 
clusters of globular, glistening bodies, of a gray or blue-gray color. Atten¬ 
tion was first called to these bodies by Muller and Iwanoff, who found them 
in sections; later observers have noticed the condition ophthalmoscopically. 
They appear as spheric bodies imbedded in the optic disc or bordering its 
periphery. They are translucent and have been compared to fr half-soaked 
grains of tapioca” (Gifford). To direct ophthalmoscopy they appear two 



Fig. 332.—Microscopic section showing hyalin bodies in the nerve-head. 

(Author.) 

(Original drawing by Dll. Carl Fisch.) 

or three millimetres in diameter, and are best observed by throwing the 
light to one side of them (Liebreich). In rare instances the hyalin masses 
may cover the nerve-head, as in the case recorded by Nieden (Fig. 333). 
The disease may occur in eyes which are otherwise entirely normal, or in 
association with albuminuric retinitis, retinocliorioiditis, or retinitis pig¬ 
mentosa. As regards the etiology of the affection, Cirincione says: “The 
first cause of this hyalin transformation and subsequent calcareous deposit in 
the papilla, however, remains to be determined.” Colloid formations found 
in the nerve-head are quite distinct from the excrescences which spring 
from the lamina vitrea of the chorioid. While hyalin bodies are more 
frequent among elderly persons, they have also been observed in children. 
There is no treatment for the disease. 



DISEASES OF THE OPTIC NERVE. 


533 


INFLAMMATION OF THE OPTIC NERVE. 

The optic nerve may become inflamed in any part of its course. It is 
customary arbitrarily to class its inflammations under two divisions: (1) 
inflammation of the nerve-head, known also as papillitis, intra-ocular optic 
neuritis, or choked disc; and (2) inflammation of the ner\e behind the 
eyeball, known as retrobulbar optic neuritis. It is evident that in the first 
form the pathologic changes can be studied by ophthalmoscopy, while in 
the second type the existence of the disease must be inferred from the sub¬ 
jective symptoms. 

Intra-ocular Optic Neuritis (Choked Disc; Papillitis; Stauungspa- 

pille)._This condition is of great importance because of the likelihood of 

its passing into atrophy, and for the further reason that the presence of 


Fig. 333. —Hyalin bodies in the optic disc. (Nieden.) 



inflammation of the nerve-head is of value in the diagnosis of certain dis¬ 
eases of the brain and of the blood. Generally the affection is bilateral. 

Symptoms. —Intra-ocular optic neuritis may show no symptoms aside 
from the ophthalmoscopic signs. Often vision will be normal or only 
slightly reduced; but it may be markedly impaired. The external appear¬ 
ance shows nothing that is characteristic of the condition. If complete 
blindness ensues, the pupil will be dilated and the iris will be immobile. 
Visual acuity may be normal, slightly or much reduced, or abolished. If the 
macular bundle of nerve-fibres is involved, vision will be seriously affected. 
The field of vision may present peripheric contraction, sector-like defects, 
enlargement of the blind spot, scotomata, or hemianopsia. The fields for 
red and green are generally lost before those for other colors. Color- 
perception may be defective in persons who present no loss of visual acuity 
and no limitation of the form-fields. It is evident that little dependence 





534 


MODERN OPHTHALMOLOGY. 


can be placed upon the subjective symptoms. The diagnosis must rest on 
the findings of the ophthalmoscope. 

The ophthalmoscopic appearances (Fig. 1, Plate XXIII) include 
hyperemia with edema of the nerve-head; obscuration of the outlines of 
the disc; the presence of a papillary swelling of the optic-nerve head of 
greater or less degree; hemorrhages; and dilation of the retinal veins, 
the arteries being of normal calibre or contracted. The swollen nerve- 
head, with its numerous distorted vessels, makes a characteristic picture. 

The Nerve-head may present only a slight hyperemia, slight swelling, 
and blurring. In pronounced cases the swelling forms an elevation of 
several dioptres’ height. The elevated area is of a grayish-white color, is 
clouded, and presents radiating striae. It gradually runs into the surround¬ 
ing retina. The boundaries of the nerve-head are obliterated and the 
location of the papilla becomes known only by the convergence of the 
vessels. The hyperemia, which is often intense, may be confined to the 
area of the swollen papilla or may also involve the adjacent retina. Hemor¬ 
rhages are often seen in the swollen tissue. In cases of intracranial growths 
which have produced double (bilateral) optic neuritis, attempts have been 
made to distinguish cerebral from cerebellar growths by the appearance of 
the swollen disc. Oliver states that in subtentorial (cerebellar) tumors the 
disc looks denser and harder than in cases in which the tumor is situated in 
the cerebrum. 

The Vessels in papillitis are tortuous and resemble a bundle of angle- 
worms. The veins are dilated, tortuous, and dark. The arteries are tor¬ 
tuous, and are either of normal or of diminished calibre. Both arteries 
and veins are partly concealed by the swollen tissue. The light-streak is 
present. Tne adventitia may be thickened, causing the appearance of white 
lines along the vessels. The tortuosity of the vessels makes a picture which 
has been compared to the head of Medusa. 

Hemorrhages, which are usually small, are not uncommon. They may 
be limited to the area of the swollen papilla or may involve the retina as 
well. They may assume various forms. When existing in the nerve-fibre 
layer of the retina, they are of flame-shape. Only a single hemorrhagic spot 
may be present or there may be numerous such areas. 

Types of Intra-ocular Optic Neuritis. —Early in the history of 
ophthalmoscopy the inflammations of the nerve within the globe were classi¬ 
fied as (1) descending neuritis, (2) cholced disc, and (3) neuroretinitis. 

1. Yon Graefe, as the result of the ophthalmoscopic study of cases 
of intra-ocular optic neuritis occurring in meningitis, assumed that the 
morbid process extended from the cerebral meninges along the course of 
the nerve. Hence the term descending neuritis. This condition is charac¬ 
terized by moderate swelling of the nerve-head, slight discoloration of the 
disc, slight changes in the vessels, and the presence of an exudation, which 
causes opacity of the papilla. The process tends to extend to and involve 
the retina. 


DISEASES OF THE OPTIC NERVE. 


535 


2. In cases presenting marked swelling of the disc, hemorrhages, and 
signs of vascular distension, von Graefe applied the term “ Stauungspapille,” 
which, in English, is choked disc. 

3. Cases presenting areas of hemorrhages along the course of the retinal 
vessels, and areas of degeneration in the retina, together with blurring of 
the edges of the optic disc, or marked swelling of the same, are known 
by the name neuroretinitis. This is a frequent condition in renal diseases. 

4. The preceding terms (Nos. 1 and 2) carried with them disputed and 
confusing ideas as to causation. Hence Leber proposed the term papillitis, 
to include all the inflammatory changes occurring in the intra-ocular end 
of the optic nerve. 

5. Monocular neuroretinitis is of rare occurrence. It may result from 
orbital causes (inflammations, traumatisms) or from intracerebral causes. 
It has been observed in anemic, rheumatic, syphilitic, and pregnant pa¬ 
tients; and may result from variola, scarlatina, or diphtheria (Millikin). 

Diagnosis. —While generally easily determined, if the media are clear 
the diagnosis of intra-ocular neuritis may present many difficulties. The 
signs of greatest value are (1) obscuration of the edges of the disc, (2) 
swelling of the nerve-head, and (3) increased redness or change in color. 
Of these, the third is of little value. Redness may be caused by hyper- 
metropia. If due to eyestrain, it will disappear in a short time under the 
influence of a mydriatic and the correction of the error of refraction. The 
disc is also subject to physiologic variations in color. Inflammation may 
cause the disc to present a lilac-gray tint. 

Obscuration of the Disc-margins is a valuable sign. Blurring of the 
disc from improper focusing may cause the beginner to diagnosticate optic 
neuritis in an eye which, except for the presence of an error of refraction, 
is normal. Fine, dust-like opacities in the vitreous humor may produce 
an obscuration resembling that which is found in the early stages of optic 
neuritis. These opacities can be seen by the aid of a strong convex lens 
placed behind the ophthalmoscope, under reduced illumination. Obscura¬ 
tion of the nerve-margins from the presence of hyalin bodies or from opaque 
nerve-fibres can scarcely be mistaken for neuritis. Tags of connective tissue 
may obscure parts of the optic disc, forming a thin, gauze-like veil, whitish 
patches, or delicate shreds. If congenital, they will hide the vessels; if 
resulting from disease, the vessels will be constricted. 

Sivelling of the Nerve-head is characteristic of intra-ocular optic neuri¬ 
tis. The difference in level between the retina and papilla can be determined 
by the parallactic test and by direct ophthalmoscopic examination. The 
prominence is best seen with the binocular ophthalmoscope. 

The congenital condition known as spurious optic neuritis may cause 

mistakes in diagnosis (see page 541). 

Etiology. —Among the causes of optic neuritis are alcoholism, anemia, 
aneurisms, caries of the adjacent bones, chlorosis, leukemia, cerebral abscess, 
cerebral hemorrhage, cerebritis, meningitis, epilepsy, chorea, general paraly- 


536 


MODERN OPHTHALMOLOGY. 


sis, disseminated sclerosis, hydrocephalus, hydatids, lead poisoning, tubercu¬ 
losis, malaria, rheumatism, gout, syphilis, injuries of the head and spine, 
myelitis, tetany, loss of blood, orbital diseases, nasal diseases, pertussis, 
typhoid and typhus fevers, renal diseases, diabetes, pneumonia, suppurative 
diseases of the ear, errors of refraction, eyestrain, tumors of the brain, 
tumors growing from the meninges or optic nerve, congenital deformities 
of the skull, pregnancy, retained secundines, heat-stroke, menstrual dis¬ 
orders, excessive lactation, checking of the lacteal secretion, and heredity. 
The most frequent cause is intracranial tumor, double optic neuritis occur¬ 
ring in from 80 to 95 per cent, of these cases. All types of morbid cerebral 
growth are likely to cause papillitis. Second in frequency as an etiologic 
factor is meningitis. The third place should probably be assigned to 
syphilis. Multiple sclerosis rarely causes optic neuritis, Uhthoff having 
found the condition only five times in one hundred cases, and in only three 
was the neuritis of high degree. 

Pathology.— In cases of pronounced papillitis the swollen nerve-head 
is seen macroscopically as a mass projecting beyond the retina. The ad¬ 
jacent retina is pushed aside and in neuroretinitis it is thrown into folds. 
In some cases an ampulliform swelling of the distal end of the optic nerve 
is present. Microscopic examination shows edema and swelling, hemor¬ 
rhagic extravasations, and varicosities of the nerve-fibres. There is slight 
infiltration of leucocytes. In interstitial neuritis the morbid process begins 
in the sheath and septa. Edema, cellular infiltration, and fibrinous exuda¬ 
tion are followed by a new formation of connective tissue. Atrophy of the 
nerve-fibres ensues and leads to scotomata and sector-like defects in the 
field of vision. 

Course. —The disease may be acute or chronic. It may appear sud¬ 
denly, reaching its greatest development within a few days; or it may come 
on slowly, lasting for months or even years and be attended with progressive 
loss of vision. Second attacks of intra-ocular optic neuritis have been 
reported. 

Prognosis. —This must be guarded, since it is impossible to determine, 
at the first examination, whether the disease will end in blindness, partial 
loss of vision, or restoration of visual acuity. The cause must be determined, 
if possible. If due to syphilis, rheumatism, disorders of menstruation, or 
anemia, the prognosis will be favorable. Intra-ocular optic neuritis which 
is produced by intracranial lesions offers an unfavorable prognosis. 

Mechanism of Papillitis.— Many theories have been advanced to 
account for the mechanism of papillitis. 

1. Von Graefe attributed the papillitis which accompanies meningitis 
to “descending neuritis.” The swelling of the nerve-head, which is found 
in intracranial diseases, he attributed to obstruction of the return of blood 
from the eye, by compression of the cavernous sinus. This, known as 
the hach-water theory, held sway until 1869, when Sesemann showed that 
the communication between the orbital and facial veins is so free that pres- 


DISEASES OF THE OPTIC NERVE. 


537 


sure on the cavernous sinus can produce only transient engorgement of the 
retinal veins. 

2. Stellwag in 185G and Manz in 1865 showed that the sheath of 
the optic nerve is distended in optic neuritis produced by brain tumors and 
meningitis. In 1869 Schwalbe demonstrated that the subvaginal space 
around the optic nerve is continuous with the subdural space around the 
brain. The same year Schmidt-Rimpler attributed papillitis to distension 
of the optic-nerve sheath, thus originating the lympli-space theory. Manz, 
who supported this theory in 1871, attributed the intra-ocular changes to 
simple pressure on the nerve and blood-vessels. Schmidt-Rimpler sug- 



Fig. 334.—Photomicrograph of the optic-nerve head in case of 
tumor of the brain. (Author.) 

1, Swollen nerve-head. 2, Retina. S, Sclera. A. Sheath of the nerve. 5, Orbital portion 

of the nerve. 

gested that optic neuritis was due to the irritant nature of the fluid dis¬ 
tending the lymph-spaces. 

3. Leber in 1881 rejected both the “mechanical pressure” idea of Manz 
and the “irritation” theory of Schmidt-Rimpler. He held that the dis¬ 
tension of the sheath is the immediate cause of papillitis, by reason of the 
conveyance of pathogenic material to the optic nerve behind the eye. This 
was the beginning of the inflammatory theory, which has undergone various 
modifications. Deutschmann in 1887 accepted it and published the results 
of confirmatory experiments. 

4. Benedikt, Hughlings Jackson, -and Brown-Sequard held that an in¬ 
tracranial tumor acts as a foreign body, causes irritation, and produces a 



538 


MODERN OPHTHALMOLOGY. 


reflex influence (via the vasomotor nerves) upon the optic-nerve head. 
This, known as the vasomotor theory, has been generally rejected because 
it involves a mechanism which may not exist. 

5. Edmunds and Lawford regard the optic neuritis which is pro¬ 
duced by intracranial lesions as due to basilar meningitis, the inflamma¬ 
tion reaching the nerve-trunk by way of its sheath. Parinaud’s theory 
is founded upon the coincidence of internal hydrocephalus and papillitis. 
Internal hydrocephalus causes a general cerebral edema. The optic nerve 
participates in the process, the papilla becomes edematous, and the subse¬ 
quent changes are due to this edema. 

6. The theory of Sourdille (1901) is founded on the coincidence of 
internal (ventricular) hydrocephalus and optic neuritis. He calls atten¬ 
tion to the fact that the anterior three-fifths of the chiasma are covered 
only by pia mater and by the visceral layer of the arachnoid, while the 
posterior two-fifths project into the third ventricle and are covered by 
ependyma. Edema, originating in the gray matter of the third ventricle, 
passes by contiguity to the neuroglia of the optic nerves. The nerve, in¬ 
creasing in size, is compressed by the unyielding optic foramen; the return 
circulation of the blood from the veins of the optic nerve, which enter the 
cranial cavity, is interfered with, as also is the lymphatic circulation. 
The interstitial edema of the nerve increases and the veins of the pia 
mater become dilated. A serous exudate, which accumulates in the sub¬ 
arachnoid spaces, appears. Destruction of the sheaths of the nerves follows, 
and thus is formed the classic ampullar dilation. The central retinal artery 
becomes contracted, but it remains pervious. The vein is reduced to a mere 
slit, and were it not that there developed a communication between the 
papillo-optic circulatory system and the vessels of the chorioid and scleral 
ring, vision would be quickly destroyed. The development of the collateral 
circulation produces those changes which are visible ophthalmoscopically 
and which are known as “choked disc.” The swelling is limited to the 
nerve-head, and does not involve the retina because of the great com¬ 
pensatory dilation which the vessels, traversing the lamina cribrosa, undergo 
in performing the extra work thus thrown upon them. Another reason 
for the limitation of the swelling is that the capillary anastomosis exists 
only in the region of the nerve-head. Hence the retina remains free of 
involvement. This capillary anastomosis influences the anatomic changes 
which are found in the lamina cribrosa. The degree of swelling varies 
with the permeability of the central retinal vein and with the relative size 
of the optic foramen. It may appear only as a cloudiness, presenting the 
appearance which von Graefe denominated “a descending neuritis.” Up 
to this, point a cure is possible, provided the cause can be removed. In 
some cases in which the tumor of the brain continues to grow, vision will 
be retained for a long period. The swelling of the papilla may diminish, 
owing to the fact that atrophy of the nerve in the optic foramen renders 
return of fluid possible; or the improvement may be due to a further devel- 


DISEASES OF THE OPTIC NERVE. 


539 


opraent of the collateral circulation through the veins of the dural sheath. 
Vision gradually is lost. Lesions of degeneration appear in the nerve. 
The peripheral fibres are the first to suffer; the central ones are involved 
later in the course of the disease. Thus all the phenomena are the result 
of edema of the ependymal neuroglia, which is an extension of the edema 
of the gray matter of the brain, found in all cases in the vicinity of growing 
cerebral tumors. 

Treatment. —This will depend upon the cause. When present in 
anemic subjects, intra-ocular optic neuritis generally yields to a course of 
treatment by tonics. If due to rheumatism, salicin, salicylate of sodium, 
the iodid of potassium or of sodium, pilocarpin, hot baths, etc., should be 
employed. When caused by syphilis, active mercurial treatment should be 
instituted and may be attended with the use of full doses of potassium iodid. 
Here pilocarpin may be useful. Some authors use these remedies simul¬ 
taneously, employing mercury by inunction, potassium iodid by the mouth, 
and pilocarpin hypodermically. If the etiology is obscure, this plan should 
be followed. The application of cups or of leeches to the temples is used by 
some surgeons with possible benefit. The eyes should be protected by the 
use of dark glasses. 

Trephining of the skull, and excision of tumors where this is possible, 
will often be followed by improvement because of the reduction of intra¬ 
cranial pressure. Local surgical measures, such as incision of the dis¬ 
tended vaginal sheath, have not met with favor. In a few cases trephining 
of the ethmoidal and sphenoidal sinuses has been followed by excellent 
results. . 

Retrobulbar Optic Neuritis (Orbital Optic Neuritis).—Inflammation 

of the orbital portion of the optic nerve may occur as an acute or as a 
chronic process. Owing to the location of the lesion, the ophthalmoscopic 
signs are either slight or not characteristic. After the neuritis has sub¬ 
sided the optic-nerve head will show atrophy. 

Acute Retrobulbar Optic Neuritis. —This, the fulminant form of 
retrobulbar neuritis, is of rare occurrence. 

Etiology .—Among the causes are rheumatism, gout, syphilis, tubercu¬ 
losis, exposure to intense cold, and infectious diseases (influenza, etc.). 
It has been seen to follow typhoid fever, carcinoma of the stomach, poison¬ 
ing by the bite of a scorpion (Gonzales), lead poisoning, and diabetes. 
Vail has observed retrobulbar optic neuritis in cases of intranasal disease 
with involvement of the sphenoid bone. The disease may follow facial 
paralysis, the optic neuritis occurring several months or years after the 
involvement of the facial nerve. Alveolar abscess, by causing orbital 
periostitis, may produce the disease. Orbital cellulitis is also a cause. 
Some patients with disseminated sclerosis show great loss of vision without 
marked ophthalmoscopic signs, one eye usually being affected. In this 
disease bilateral involvement is more frequent in the form of chronic 
retrobulbar optic neuritis. 


540 


MODERN OPHTHALMOLOGY. 


Symptoms .—The symptoms include sudden diminution or obscuration 
of sight, beginning in the centre of the field and leading rapidly to great 
loss of vision or to complete blindness. In some cases the papilla is 
swollen and both eyes are affected, thus resembling the intra-ocular optic 
neuritis which is associated with intracranial disease. In such retrobulbar 
cases the changes in the disc are not gross, and there is an absence of other 
symptoms of intracranial disease. Orbital pain and tenderness are present 
in this form of retrobulbar neuritis. However thorough the restoration 
of vision may be, the optic disc in cases of retrobulbar neuritis shows evi¬ 
dence of the past attack, in the form of pallor of the temporal half of the 
nerve-head. Blindness may appear in from one to eight days. Headache 
or dull pain in the orbit is generally present. At first the ophthalmoscope 
shows nothing pathologic; but later the nerve-head becomes hyperemic, 
the margins are blurred, the surrounding retina is hazy, and, in rare 
instances, small retinal hemorrhages and grayish or yellowish spots of 
exudation appear in the macular area. The arteries may be diminished in 
calibre, while the veins are enlarged and tortuous. Movement of the eye, 
or direct backward pressure upon it, will cause pain. Pain is limited to 
the diseased side and is unaccompanied by vomiting. Occurring in cases of 
acute or subacute myelitis, there may be marked swelling of the nerve- 
head. Obviously the line between intra-ocular and retrobulbar optic neuri¬ 
tis is sometimes an arbitrary one. After weeks or months signs of atrophy 
of the optic disc appear. Usually only one eye is involved. If the second 
eye becomes affected, there is generally an interval of months. Visual 
acuity is worse in a bright light. Patients often complain of seeing objects 
as through a moving haze. Dimness of sight may be complained of where 
vision is 6 / 6 ; and color-scotomata may be found. As a rule, vision is 
reduced to one-fourth or one-third the normal. With the decline of the 
acute symptoms, the ophthalmoscopic evidences of optic-nerve atrophy 
become manifest. 

Pathology .—The changes include atrophy of the nerve-fibres, increase 
of the nuclei, and thickening of the trabeculas and of the walls of the small 
vessels. Gunn states that pallor of the optic disc occurring subsequent to 
retro-ocular neuritis does not necessarily mean atrophy of the nerve-fibres, 
but may be due to increase of connective tissue secondary to lymphatic 
obstruction. 

Diagnosis .—The disease is to be differentiated from suddenly dis¬ 
covered congenital amblyopia and from hysteric amblyopia. 

Prognosis .—Acute retrobulbar optic neuritis runs an acute course, 
which ends either in complete or in partial recovery. Recovery of useful 
vision is possible if improvement begins early. Nettleship believes that the 
affection may be a forerunner of spinal-cord disease. In favorable cases- 
vision will become normal. In unfavorable ones there will be a central 
scotoma. Since the disease may cause blindness, a guarded prognosis should 
be given. 


DISEASES OF THE OPTIC NERVE. 


541 


Treatment .—Where possible, this must be carried out according to the 
etiology of the disease, Rest of the eyes and the energetic use of dia¬ 
phoretics will be advisable. If rheumatism is regarded as a cause, salicylate 
of sodium should be given. 

Chronic Retrobulbar Optic Neuritis (Toxic Amblyopia). —This 
may follow repeated acute attacks, or the disease may be chronic from the 
beginning. 

Etiology .—Among the causes are rheumatism, gout, exposure to cold, 
periostitis, meningitis, disseminated sclerosis, systemic poisoning with 
drugs, and heredity. The cases which are due to poisoning with drugs 
are classified as instances of toxic amblyopia and are discussed elsewhere 
in this chapter. 

Symptoms .—There is gradual reduction in visual acuity, with the pres¬ 
ence of a central scotoma. The ophthalmoscopic findings may be negative 
or there may be pallor of the temporal segment of the optic disc. The 
symptoms will be more fully considered under “Toxic Amblyopia.” 

Prognosis -—This is favorable, provided the cause can be removed before 
atrophy of the nerve-fibres ensues. 

Treatment .—This will be the same as that given for toxic amblyopia. 

Optic Neuritis with Nasal Discharge.—A few cases have been reported 
in which there was persistent dropping of watery fluid from one side of the 
nose (usually the left), preceded or followed by severe cerebral symptoms, 
and associated with optic neuritis, which led to atrophy and blindness. 
The cerebral symptoms include headache, vertigo, vomiting, stupidity, epi¬ 
leptiform seizures, sleepiness, delirium, coma, loss of power in the lower 
extremities, great reduction or complete loss of vision, and papillitis. 
Both eyes are affected. Analyses of the nasal discharge have not shed much 
light upon the nature of the disease. In Nettlesliip’s case the fluid was 
attributed to a diseased nasal mucous membrane, and did not show the 
characteristics of cerebro-spinal fluid. Priestley Smith, who observed two 
cases of this rare disease, inclined to the view that disease of the nose or of 
its accessory cavities is responsible for the cerebral symptoms. Leber has 
recorded a case of internal hydrocephalus associated with dropping of fluid 
from the nose. He believes that the fluid had its origin in the third ven¬ 
tricle, escaping through an opening in the ethmoid bone, or from the 
subdural space via lymph-spaces surrounding the olfactory nerves. The 
whole subject demands further study. The prognosis is unfavorable both 
as regards vision and life. Treatment thus far has been without result. 

Spurious Optic Neuritis, although it is a congenital anomaly, will be 
mentioned in this place. The term is used to describe a condition in which 
the nerve-head is unusually prominent, the disc-margins are blurred, and 
white lines accompany the unusually tortuous retinal vessels. The disc 
may be red, giving the appearance of hyperemia; or it may be pale and 
blurred, resembling a subsiding neuritis. The prominence of the disc is 
sufficient to permit the expert ophthalmoscopist to measure it. Since these 


542 


MODERN OPHTHALMOLOGY. 


appearances are observed only in hypermetropic eyes, the term hyper¬ 
metropic disc seems to be appropriate. The degree of error has no influ¬ 
ence upon the anomaly. So closely does spurious optic neuritis resemble 
true inflammation of the nerve-head that the differentiation can be made 
only by the fact that the former condition remains stationary. Vision in 
these cases is usually normal after the refraction-error has been corrected. 
The fields of vision are also normal. 


TOXIC AMBLYOPIAS. 

Toxic Amblyopia.—This term is applied to cases of dimness of vision 
which are caused by toxic substances. Among the synonyms are chronic 
retrobulbar optic neuritis; intoxication-amblyopia; alcohol-amblyopia; 
quinin-amaurosis; tobacco-amblvojfia; malarial amblyopia, etc. 

Etiology. —The agents which are capiable of producing toxic am¬ 
blyopia are numerous. Among them are alcohol, tobacco, bisulphid of car¬ 
bon, iodoform, stramonium, tea, coffee, chocolate, thyroidin, salicjdic acid 
and the salicylates, lead salts, quinin, oil of wintergreen, filix mas, 
pelletierin, nitrobenzol and dinitrobenzol, anilin, ergot, the venom of ser¬ 
pents, mercury, phosphorus, sulphur, antipyrin and antifebrin, carbolic 
acid, cannabis Indica, conium, digitalis, carbonic acid gas, naphthalin, 
santonin, mescal, strychnin, nitrite of amyl, the mydriatic drugs, gel- 
semium, curare, cocain, eucain, holocain, benzin, nitroglycerin, etc. The 
patients are generally males of or above the age of forty years. 

Symptoms. —The chief symptom is a disturbance or loss of vision. 
The patient will complain of “misty/’ “smoky,” or “foggy” vision. He 
will notice difficulty in reading, and this will cause him to ask the surgeon 
for glasses or for a change in lenses. At this early stage central vision may 
be normal or only slightly reduced. Ophthalmoscopic examination will 
show a pallor of the temporal segment of the nerve-head, with or without 
slight blurring of the margins of the disc. The nasal side of the disc may 
be hyperemic. Perimetric examination made at this time will show the 
presence of negative central scotomata, which are of oval shape and include 
the blind spots and fixation-points. In this zone there is loss of color- 
vision. Green is the first color to disappear, and is followed by the loss of 
red and blue. Finally form-perception is lost in this area. 

In advanced cases vision is reduced to 20 / 40 or even to e / 200 for far, 
and, to the reading of Jaeger, 5 to 14 for near. The temporal segment of 
the nerve-head is then of a chalky-white color. 

Pathology. —Holden and Huel have shown that the first change in 
toxic amblyopia is chromolysis of the retinal nerve-cells. This progresses 
and the nerve-cells are destroyed. The optic-nerve changes—destruction 
of nerve-fibres, proliferation of the interstitial connective tissue, etc.—are 
secondary to the retinal lesions. It seems to be definitely settled that quite 
diverse types of optic neuritis are of parenchymatous nature. These neu- 


DISEASES OF THE OPTIC NERVE. 


543 


ntides are tabetic retrobulbar optic neuritis, infectious microbic optic neuri¬ 
tis, simple white atrophy, and some forms of papillitis. Birch-Hirschfeld 
states that the pathologic changes in toxic amblyopia have a double origin 
(m the retina and in the optic nerve), but thinks that the ganglion- 
cell changes in the retina precede or at least come at the same time as the 
nerve-fibre degeneration. 

Quinin-amaiirosis. Quinin may cause a temporary amblyopia or an 
amaurosis which presents grave symptoms. While this condition is called 
qumm-blindness, it may be caused by any of the alkaloids found in the bark 
or may result from a large dose of the tincture of the bark. The sulphate 
and bisulphate of quinin are more active than other salts. Owing to the 
fact that in most of the cases the patients were suffering from general dis¬ 
eases,—such as malaria, syphilis, meningitis, pneumonia, typhoid fever, 
gastro-enteritis, etc., it has been doubted that the blindness was due to the 


Fig. 335. Fields of vision in a case of quinin-amaurosis. (Author.) 

Taken two weeks after the ingestion of sixty grains of the drug in twenty-four hours. 

ingestion of quinin. On the other hand, the exact clinical picture of 
quinin-amaurosis can be produced in dogs. 

The dose causing blindness has varied from 15 grains to 1 ounce in 
twenty-four hours. Occasional^ temporary blindness has appeared after 
the administration of 15 grains in divided doses in twenty-four hours. Of 
69 cases gathered from literature by de Schweinitz, 42 were males, 20 
females, and in 7 the sex was not given. The ages varied from 3 to 65 years. 
Thirty-four were under 40 years of age. One case is recorded in which a 
negro became blind from quinin. 

The symptoms of quinin-amaurosis are:— 

1. Total blindness following the ingestion of large quantities of quinin. 

2. Contraction of the visual fields. 

3. Marked contraction of the retinal blood-vessels. 

4. Pallor of the optic discs. 

The pupils are widely dilated and do not contract on exposure to light; 
but, according to some observers, they contract to a slight extent on accom- 










544 


MODERN OPHTHALMOLOGY. 


modative effort. This was true of a patient seen by the author. Ery- 
thropsia has been observed in one case. 

Pathology.— To explain the occurrence of this type of amaurosis we 
must look to the vasomotor system. In dogs poisoned by quinin de 
Schweinitz found thickening and changes in the walls of the optic-nerve 
vessels (endovasculitis), thrombosis of the central artery with organization 
of the clot, and complete atrophy of the visual tracts. Holden has shown 
that the toxic effect is exerted primarily upon the ganglion-cells of the 
retina. 

Diagnosis.- —Quinin-amaurosis might be mistaken for embolism or 
thrombosis of the retinal vessels. These affections are unilateral, while 
quinin-amaurosis is almost always bilateral. 

Prognosis is favorable so far as the restoration of central vision is 
concerned. In grave cases the visual field is not restored in its entirety. In 
one instance the patient was practically blind two years after the adminis¬ 
tration of quinin, vision in the better eye being equal to perception of move¬ 
ments of the hand at six feet. It is probable that other cases equally 
unfortunate have occurred, but have not been reported. 

Treatment. —The drug should be discontinued. The patient should 
be placed in the recumbent position. He should be fed with nutritious 
substances, such as beef-broth, soups, etc. Inhalations of nitrite of amyl 
can be cautiously tried. Strychnin should be used by the mouth or hypo¬ 
dermically. 

Methyl-alcohol Amblyopia.—Owing to its cheapness, wood-alcohol is 
coming into extensive use in the arts, replacing ethyl-alcohol. Methyl- 
alcohol when taken by the stomach, or when inhaled, may cause blindness. 
Most of the reported cases concerned persons who had become drunk by the 
use of wood-alcohol or had imbibed freely of a cheap quality of Jamaica 
ginger. The disease has been observed also among artisans (painters, shel- 
lackers) who work with preparations containing wood-alcohol. The poison¬ 
ous action of the drug is manifested by headache, vomiting, dizziness, and 
dimness of vision. The pupils will be widely dilated and may react to 
light, but not to accommodation. The field of vision will be contracted 
peripherally and will show a central scotoma; and there will be a reduction, 
of greater or less degree, of visual acuity. In a few days, vision may im¬ 
prove, but the improvement is only temporary. Ophthalmoscopic examina¬ 
tion will give different results, according to the time which has elapsed 
since the intoxication and according to the amount of the toxic substance 
imbibed or inhaled. 

Early in the case there may be no visible changes. Sherer, on the 
other hand, records a case in which examination made one day after in¬ 
toxication showed a greenish-white discoloration of both optic-nerve heads, 
together with atrophic cupping. 

Diagnosis.— The history of imbibition of methyl-alcohol or of prepara¬ 
tions containing it, or exposure to its fumes, together with such symptoms 


FLUTE XXII. 

Diseases of the Optic Narva. 


Fig. 1.—Primary, or Simple, Atrophy of the Dptic Nerve. 


Fig. 2,—Secondary, dp Cause 


nutivs, Atrophy of the Dptio Nerve, 


. J.IXX, 

.eviEX aUqQ siit la ebbebsIEI _ 

.. . a patient seen by the author. hry- 

i " ,. '^va^^rrence of this type of amaurosis we - 
. ..f. ;n. In clogs poisoned by qumm do 
, ^Vchttugee in the wails of the opnc-nerve. 

: .[ the central artery with organization 
vf the visual tracts. Holden has shown 
, t ; 6 e .crted 'primarily upon’the ganglion-calls <rf the 

9 

om-in+mtoxe* n>W be mWakea for embolism or 
. , liT) ; vessel*. The-« affections are unilateral, wnue 
, . t ■ p ) l' v ■ <' ’ b iia i (* r 1 1 1 

BV raVT yiiqb' akt lo'triqQTtA ,.slqml3 i:q ' ■ 1 ri'.-Il is 

s is favorable so ai a- \ • " " ,, 1t , 

Ju * .***< tie P>t field -not». toved in its entnei. - 

». r • ■<" w: '" ! *«> > eara aftei the * u “ u “ 8 * 

, r mimn virion a i H. tt r -■ brio* ecjuai to ;«-o ption ot mow- 

«• Jte hand ot i' • >> ‘ ptobobk that otto <M> 

\ have not been twjhyru’d. 

. . 1 in; ilis'-ont'nnu'ct. 'Alie patient tuOulu_ 
j , ;j,,) i,] be fed with nutritious 
( i-. Uil d irh-ns of nitrite of amyl 
,1J be used oy the mouth or hypo- 


l ittPate haw- oceiivr 

' , V. MtN'T.— ill . 
;)U tw€ JEjH'till’’ 

- ^ : i as ty 










Clp 




ih ohoi is 




u- v had b* ••''nit driw by ho - 
•ne in in ; voM-tdrol >h T he 

‘ 

ill be widely dilated an 11 mu; rcoet to < 

, . ,1. . e i; of vis ■ - ji wil- h oraVted 

h -r'toma-; and there will be a reduction, 

; , ,iitv. In t few days, vision may im- 

ji i, jorary. Ophthalmoscopic examina- 

.svitiVl ottqO sill io ydqn^lS ,Btr£firdB2J3Dp au ,V'ri.jsapoe.'7—,S ,pi r i .q 

■ 

» -<• -visible changes. Sheroc, on the 
. , v rdriation made one day alter in- 

untiou of both optic-nerve heads, 

of methyl-alcohol or of prepara- 
. . .. pit, ,, together with such symptoms 



PLATE 22 












r , 





























■ 






DISEASES OF THE OPTIC NERVE. 


545 

as headache, nausea, vomiting, dizziness, mental disturbances, and loss of 
vision, will lead to a correct deduction. 

Prognosis must be guarded. 

. .. Tkea ™ ent -—'This includes pilocarpin sweats and the use of potassium 
lodid and strychnin. 

Ptomain-poisoning (Allantiasis; Botulism).-The toxic substances 
found in decaying meats, in putrid fish, "high” game, decomposed sausage, 
etc., cause amblyopia. Other ocular symptoms are paresis or paralysis of 
the accommodation, ptosis, and paralysis of the extra-ocular muscles. If 
death does not occur, the ocular symptoms may rapidly disappear. In 
some cases the paralyses remain and are attributed to nuclear hemorrhages 
or to basilar meningitis. Treatment will consist of stimulants, tonics, e & tc. 

ATROPHY OF THE OPTIC NERVE. 

Atrophy of the Optic Nerve.—The term atrophy of the optic nerve 
is applied to conditions in which there is a degeneration of the nerve-fibres 
and an overgrowth of connective tissue. The disease may be primary or 
secondary. J 

Primary Optic-Nerve Atrophy (Fig. 1, Plate XXII) develops with¬ 
out previous visible signs of inflammation. As a rule, both eyes are 
involved, the process being more advanced in one than in the other. The 

optic disc is shallowed and changed in color, and the disc-margins are 
clearly defined. 

Secondary Optic-Nerve Atrophy (Fig. 2, Plate XXII) develops as 
a result of a previous inflammatory process, which may be located in the 
brain or its membranes, in the chorioid, in the retina, or in the nerve-head. 
The disc-margins are blurred by the deposition of connective tissue upon 
them. The distinctions given above are based on clinical appearances. 
Pathologic studies have shown that, in many cases, what clinicians call- 

simple or primary atrophy of the optic nerve is due to parenchymatous 
neuritis (Nuel). 

External and Subjective Symptoms. —The external appearance is 
that of the normal eye, except that in total blindness the pupils will be 
dilated and irresponsive to light. In some cases, particularly those due to 
tabes, the pupils are small, reacting to accommodation and convergence, 
but not to light (Eobertson pupil). Pain and photophobia are generally 
absent. The disturbance in vision is manifest in a lowering of visual acuity, 
a contraction of the form-field, and a contraction of the color-field. 

1. The loss of central vision varies from a slight reduction to com¬ 
plete blindness. Any existing error of refraction should be corrected before 
deciding that a loss in visual acuity is present. If the atrophy is bilateral, 
the loss of vision is generally greater on one side. Vision is impaired both 
for distance and for near. 

2. Contraction of the field for white is found at an early date. The 
common defect is a concentric contraction which progresses until only a 


25 


540 


MODERN OPHTHALMOLOGY. 


small central vision-area remains. Quadrant-shaped defects, hemianopsia, 
and central and ring-shaped scotomata have been observed. 

3. Contraction of the color-field is an almost constant symptom, the 
colors being lost in the following order: Green, red, blue, yellow. 

4. The light-sense is diminished. 

Ophthalmoscopic Changes are found in the nerve-head, in the sur¬ 
rounding tissues of the fundus, and in the blood-vessels. 

In primary atrophy (Fig. 1, Plate XXII) the margins of the optic 
disc are well defined. The disc itself presents a stippled appearance, and 
is of a grayish or bluish color. The surface of the disc is slightly concave, 
and the physiologic cup is not filled. The vessels are slightly reduced in 
calibre. The fundus looks normal. 

In secondary atrophy (Fig. 2, Plate XXII) the disc-margins may be 
irregular, and are blurred in places. The disc is of a dead-white color. 
It may show a network of newly formed blood-vessels. The surface of 
the disc is flat, the physiologic cup being filled. The vessels are diminished 
in calibre and white streaks accompany them. The fundus has lost some of 
its brightness. 

The Retinal Type of Optic-Nerve Atrophy. —Optic-nerve atrophy, 
which is secondary to retinal degeneration, will show a picture different 
from those described above. The disc will appear yellowish, or, as Frost 
says, waxy or of the color of dirty parchment. The surface of the disc 
will be flat, and often it will be surrounded by a narrow ring of atrophic 
chorioid. 

Embolic Atrophy. —Here (Fig. 2, Plate XVI) the disc shows a 
dense, opaque white or a yellowish-white appearance. Retinal changes 
are present. 

Etiology .—Any cause which may produce optic neuritis may also lead 
to optic-nerve atrophy. Brain-tumors, injuries to the nerve-trunk, con¬ 
genital malformations of the skull, erysipelas, orbital cellulitis, hemorrhage 
into the orbit, blows upon the head, spinal injuries,, syphilis, tabes, tumors 
of the pituitary body, disseminated sclerosis, progressive paralysis, cerebral 
softening, severe hemorrhages, lightning-stroke, internal hydrocephalus, 
etc., are among the etiologic factors. The abuse of alcohol and tobacco 
is responsible for some cases. Others are congenital or possibly may be 
due to injury during instrumental delivery. In probably 60 per cent, 
of the cases there is not a discoverable cause. Many of these must be 
attributed to the influence of certain toxic substances which are generated 
in the system as the result of perverted metabolism. This view of the 
endogenous origin of certain cases of optic-nerve atrophy was suggested by 
Horner. Recent studies of the excretions of patients suffering with tobacco- 
amblyopia have shown excessive excretion of enterogenous decomposition- 
products in the urine, together with a more or less marked urobilinuria 
(de Schweinitz and Edsall). 

Of 117 cases of optic-nerve atrophy, Derby found no cause in 71; 


DISEASES OF THE OPTIC NERVE. 


547 


abuse of alcohol and tobacco, 11; syphilis, 8; injuries to the head, 9; brain 
disease, 6, apoplexy, 1; epilepsy, 1; locomotor ataxia, 1; meningitis, 2; 
optic neuritis, 2; erysipelas following lacrimal abscess, 1; mumps, 2; 
tumor of pituitary body, 1; following pregnancy, 1. 

Pathology.- The pathologic changes will depend upon the etiologic 
factor. In the atrophy found in tabetic subjects the nerve-fibres lose their 
medullary coverings and are changed into fine ftbrilke. Fatty granular 
cells are found between the fibrillae. There are no signs of a true inflam¬ 
matory process. Holden believes that the primary change is an atrophy of 
the retinal ganglion-cells. 

In the post-neuritic type of atrophy there is a formation of connective 
tissue in the nerve-stalk and in the nerve-head. The coats of the vessels are 
thickened. The sheaths of the nerve-fibres show varicosities and either 



Fig. 336. Deformity of the skull producing exophthalmos, divergent 
strabismus, and atrophy of the optic nerve. (Risley.) 


shrink or disappear. In advanced cases the nerve forms a hard, distorted 
cord (Fig. 337). 

Prognosis. I his is always grave, and will depend on the cause of the 
disease, the stage at which the patient applies for treatment, etc. In 
primary or progressive atrophy the course of the disease is slow. Several 
years may elapse before the patient becomes blind. The damage done to 
vision in the neuritic or secondary form will depend upon the amount of 
contraction which ensues in the inflamed tissue. A progressive narrowing 
of the field is a sign of grave import. 

Treatment must be directed in accordance with the cause. Syphilitic 
cases will require mercury or potassium iodicl, or both remedies. Strychnin 
must be given by the mouth or hypodermically. It should be administered 
in rapidly increasing doses and should be pushed to the limits of tolerance. 
If administered hypodermically the beginning dose will be 4 / 100 grain. 
Given by the mouth the begining dose will be V 60 grain three times a day, 
increased rapidly until the patient takes 1 / 0 or 1 / B grain at a dose. Accord- 










54S 


MODERN OPHTHALMOLOGY. 


ing to Derby, improvement follows the strychnin treatment in 30 per cent, 
of the cases. Nitroglycerin or nitrite of amyl may be used. Other pro¬ 
posed remedies are preparations of arsenic, silver, iron, phosphorus, lactate 
of zinc, hypodermics of antipyrin, and galvanism. Vibratory massage may 
be tried. 

If no improvement follows the use of such remedies as have been 
enumerated, the author removes the superior cervical ganglion of the sympa¬ 
thetic nerve, in the hope that an increased blood-supply will bring about im¬ 
provement in vision. Although it is yet too soon to pass final judgment 
on this operation, the author has had one successful result out of four ad¬ 
vanced cases of optic-nerve atrophy which he has treated by operation. To 
be of value, the operation should be done while the patient retains vision 



Fig. 337.—Atrophy of the optic nerve following phthisis bulbi. 

(Author.) 

(Photomicrograph by Dr. H. P. Wells.) 

equal to or better than the counting of fingers at two or three feet. Suker 
and Renaud have also reported cases in which sympatheticectomy was 
followed by improvement in vision. 

Hereditary Optic-Nerve Atrophy. —This is a variety of atrophy of 
the optic nerve which, as a rule, affects several members of a given family at 
about the age of twenty years. . It has been known to affect as many as six 
generations (Gould). The disease is found chiefly in the male members, 
the inheritance being through the unaffected females. About 14 per cent, 
of the cases reported have occurred in females. There are on record 317 
cases, occurring in 80 families. 

Symptoms .—The onset of the disease is sudden. It begins as an acute 
retrobulbar neuritis, which reaches its height in five or six weeks. After 




DISEASES OF THE OPTIC NERVE. 


549 


this peiiod it either progresses slowly or remains stationary. Central 
scotoma is present, which at first affects colors only and ultimately involves 
the form-field. Peripheral vision is either normal or slightly altered, thus 
permitting the patient to get about, while central vision is often so much 
reduced that reading is impossible. The color-changes are central at first, 
the periphery becoming involved later. Blue and yellow are seen more 
cleaih than red. In anomalous cases a ring-scotoma or a sector-shaped 
defect may be found. Nyctalopia is a common symptom. During the 
stage of inflammation the patient may complain of red vision or of seeing 
colored stars or flames. Photophobia and headache may be present. The 
ophthalmoscopic signs include hyperemia of the nerve-head with slight 
haziness of its outline. The arteries are either normal or dilated (Leber). 
A fine striated appearance of the retina around the nerve-head may be 
piesent. In the later stage the papilla becomes white, with slightly hazy 
borders and an accumulation of pigment. The pallor of the disc generally 
begins in the temporal half. Atrophy always follows the neuritis. 

Etiology. Heredity is an undoubted factor. Some cases have been 
attributed to the abuse of tobacco and alcohol. The tower-shaped skull has 
been regarded by some writers as a cause, it being supposed that the optic 
nerve is compressed by the bone. 

Prognosis. This is unfavorable. Leber has seen a family in which 
all the patients recovered their vision. Partial recovery has been noted 
by several observers. 

Treatment, flhis does not differ from that which is appropriate for 
other types of retrobulbar optic neuritis. 

Hemorrhage into the Sheath (Apoplexy) of the Optic Nerve.—Al¬ 
though hemorrhage into the subdural and subarachnoidal spaces of the optic 
nerve has been described by Magnus, de Wecker, and others, there is no 
evidence to show that it exists as an idiopathic affection. There are no 
reasons for believing that hemorrhages situated at the border of the optic 
disc, or in the vitreous humor, are indicative of apoplexy of the optic-nerve 
sheath (Gonin). Intervaginal hematoma may occur after cerebral apoplexy 
or following trauma. In such a case there will be rapid and great loss of 
vision. Early ophthalmoscopic examination may show nothing abnormal, 
or may give a picture resembling that which is found in embolism of the 
central retinal artery. At a later date the disc will be atrophic. 

DISTURBANCES OF VISION WITHOUT APPARENT LESION. 

Under this heading will be considered certain ocular affections (am¬ 
blyopia, amaurosis, color-blindness) in which, as a rule, no changes are 
visible within the eye. Probably future investigations, aided by instru¬ 
ments and methods of greater precision than those now existing, will 
remove certain of the amblyopic affections from this category and place 
them in the list of organic diseases. The term amaurosis indicates com- 


550 


MODERN OPHTHALMOLOGY. 


plete blindness, and amblyopia partial blindness, without discoverable fun¬ 
dus lesions. The term amblyopia is not applied to those conditions in 
which the reduction in visual acuity is due to an error of refraction, and 
becomes normal or approximately normal after its correction. 

Congenital Amblyopia is the name applied to that condition in which 
there is congenital deficiency of vision and all other causes can be excluded. 
Generally only one eye is involved. It may be hypermetropic, myopic, and 
astigmatic. It may show the presence of such abnormalities as coloboma, 
etc., or these defects may not be present. Correction of the error of refrac¬ 
tion does not bring the acuity of vision to the normal or near the normal 
grade. In such cases it is assumed that structural changes exist in some 
part of the ocular nervous system exterior to the eyeball. In some cases 
of congenital amblyopia the correction of the refraction-error is not 
followed immediately by improvement, but, after the use of glasses for a 
variable period, there comes an increase in visual acuity. Under the name 
astigmatic amblyopia Martin has described a type of congenital deficiency in 
vision which he believes is due to imperfect development of the finer parts 
of the retina, owing to asymmetrical stimulation. If both eyes are con¬ 
genitally amblyopic, nystagmus will result. 

Acute Amaurosis following Infantile Convulsions has been described 
by Pettiest)ip, Gay, Ashby, and Stephenson. Post-eclamptic amaurosis is 
attributed to anesthesia of the visual centres. Aphasia and hemiplegia ac¬ 
companying the visual disturbance may be transient or permanent. The 
amaurosis is generally transient, most patients recovering their vision in 
a few days. The convulsions are severe and are accompanied by coma. 
There are no discoverable lesions of the fundus. 

Congenital Amblyopia for Colors (Color-blindness; Dichromasia; Dal¬ 
tonism).—Color-blindness is a subject of which much has been written and 
but little is known. The condition exists in about 4 per cent, of males, 
according to Tscherning, but is much less common (0.02 per cent.) in 
females. While it is usually congenital, in rare instances color-blindness 
is acquired. 

Persons who are color-blind will (in using the worsted-skein test) 
pick out gray, light pink, or yellow worsteds and will add them to the green 
skeins. In the next test the rose-purple skein should be matched. If the 
patient adds blue or violet skeins, he is completely red-blind; if he adds 
the green or gray skeins, which shade toward the blue, he is completely 
green-blind. Next, he is to match red.' If in addition to the red he 
chooses the green and brownish skeins, which are darker than red, he is 
red-blind. If he selects skeins which are lighter than red appears to the 
normal eye, he is green-blind. Various tests for color-blindness have been 
described in Chapter IV (page 129). Color-blindness is incurable. 

Theories of Color-perception.- —Of the many theories which have 
been advanced to explain color-perception only those of Young, Helmholtz, 
Iiering, and Preyer will be mentioned, and these but briefly. 


DISEASES OF THE OPTIC NERVE. 


551 


Youngs Theory is thus set forth in his own words: “It is certain 
that we can produce a perfect sensation of yellow and blue by a.mix¬ 
ture of green ancl red light, and of green and violet light. There are 
reasons for supposing that these sensations are always composed of a com¬ 
bination of separate sensations. This supposition at least simplifies the 
theory of colors; we may therefore accept it with advantage until 
such time as we shall find it incompatible with some phenomenon. We 
shall pioceed, therefore, to consider white light as composed of a mixture 
of three colors only—red, green, and violet.” This theory assumes that 
each nerve-fibre of the retina is composed of three secondary fibres, each one 
of which on irritation gives rise to the sensation of red, green, or violet. 
Color-blindness is explained by Young’s hypothesis by the assumption that 
one of the secondary fibres is absent. This theory, while attractive by its 
simplicity, does not accord with modern observations on color-vision. It 
requites that from a mixture of three fundamental colors all existing hues 
shall be produced—an impossible condition. 

The IIelvnholtz-Y oung Theory. —Helmholtz modified the theory of 
Young, and assumed that each spectral color irritates three fibres at once, 
but in different degree. He explained color-blindness by absence of one 
of the fibres, as Young had done. Many objections have been raised against 
this theory. 

liering s Theory assumes the existence of a “visual substance” which 
is a mixture of three others. One of these determines white and black; 
another, red and green; and the third, yellow and blue. It is an unprofit¬ 
able task to follow this theory, which, as well as that of Helmholtz, has 
given rise to a vast amount of controversial literature. 

Preyers Theory assumes that the sense of color has been developed 
from the sense of temperature. 

Amblyopia ex Anopsia (Amblyopia from Non-use; Argamblyopia).— 

These terms indicate a loss of vision by reason of the total or partial exclu¬ 
sion of one eye from the visual act. The inability to act with the fellow- 
eye may arise from an opacity in one of the dioptric media (leucoma of the 
cornea, congenital cataract, impervious persisting pupillary membrane), or 
it may be the result of strabismus. The amblyopia accompan} T ing stra¬ 
bismus may be congenital, the defective vision causing the strabismus. On 
the other hand, it is well known that squinting eyes, which possessed good 
vision early in life, after long-continued non-use may lose even the power 
of fixation. Gould states that, in some cases classed with congenital am- 
blyopia, there are fine chorioidoretinal changes in the macular region, which 
are the result of long-continued ametropia. Amblyopia may come from the 
non-use attending persistent blepharospasm (see page 189). 

Treatment of this form of amblyopia consists in the early removal of 
the obstacle to vision, the correction of errors of refraction, and the exercis¬ 
ing of the affected eye. The discission of cataract at a very early age is im¬ 
portant. 


552 


MODERN OPHTHALMOLOGY. 


Uremic Amaurosis. —Blindness without demonstrable changes in the 
retina or optic nerve is a symptom in persons with chronic nephritis. It is 
more frequently found in the acute nephritis of scarlatina, variola, and 
measles and in the nephritis of pregnancy. It always involves both eyes 
and appears suddenly, the patient becoming suddenly blind and remaining 
in this condition for from eight to twenty-four hours. In most cases vision 
is completely lost, but in some instances perception of light exists during the 
attack. 

Severe cerebral symptoms—such as headache, vomiting, epileptiform 
convulsions, and coma—are rarely absent. They may precede the blind¬ 
ness or they may follow it. During the attack the urine is generally 
lessened in amount; rarely diuresis has been observed. Some authors have 
recorded the absence of albumin from the urine during the attack, although 
it was to be found both before and after the seizure. Uremic amaurosis may 
be the first sign of renal disease and may be associated with deafness. 

Although in the majority of cases of uremic amaurosis blindness of 
both eyes appears simultaneously, Leber has recorded a case in which first 
one eye became blind, and the next day vision was lost in the other. 

During the attack the pupils are either widely dilated and immobile or 
they react to light in spite of the complete loss of vision. Schmidt- 
Bimpler considers the latter condition to be the rule, to which there are 
exceptions. The presence of the pupillary reaction is a favorable symptom, 
since it indicates that the optic nerve is normal and atrophy need not be 
feared. 

Ophthalmoscopic examination generally shows no changes in the fun¬ 
dus, but exceptionally transient optic neuritis, dilation of the retinal veins, 
and slight retinal edema have been observed. 

The prognosis of uremic amaurosis is favorable. The blindness rarely 
fails to disappear in from twelve to twenty-four hours, and full visual 
acuity is reached in two or three days. During recovery transient defects 
in the visual field are often observed. Repeated attacks may occur at 
intervals of weeks or months or during repeated pregnancies. Permanent 
blindness from uremic amaurosis has not been observed. Where vision is 
permanently lost, changes will be found in the retina or in the optic 
nerve. 

The treatment must be directed to the general condition of the patient. 

Diabetic Amaurosis (Glycosuric Amblyopia). —Diabetic patients not 
infrequently become partly blind without showing fundus changes. La¬ 
grange estimates the frequency of this form of visual disturbance at 4 per 
cent., while Schmidt-Rimpler states that it is present in 10 per cent, of 
cases. Mauthner has contended that diabetic amblyopia depends upon the 
abuse of tobacco and alcohol; but this view has been shown to be incorrect, 
since amblyopia has been found in diabetics who did not use tobacco or 
alcohol. Leber believes that the existence of diabetes renders the patient 
more susceptible to the toxic effect of tobacco. 


DISEASES OF THE OPTIC NERVE. 


553 


The diagnosis of diabetic amaurosis will depend upon the result of an 
examination of the visual field and the exclusion of the use of those sub¬ 
stances which produce intoxication-amblyopia (alcohol, tobacco, etc.). In 
addition to the loss of visual acuity, there is at the fixation-point and its 
vicinity a scotoma for red and green. Early in the case, and also later, 
when the patient has almost recovered, the test-object will appear dimmer 
than under normal conditions, without entirely vanishing. In advanced 
cases the scotoma becomes absolute. The peripheral part of the visual 
field is generally normal. The central scotoma is often of small extent. 
As a rule, it extends about equally in all directions from the fixation-point, 
but is somewhat broader on the temporal side. Generally it does not as¬ 
sume the shape of an oval, involving both the fixation-point and the blind 
spot, which is particularly characteristic of tobacco- and alcohol- amblyopia 
(Groenouw). Since the scotoma may be easily overlooked, small test- 
objects should be used in the examination. 

Anomalous cases occur in which the field is concentrically contracted 
or hemianopic. While most cases of diabetic amblyopia will show the 
form of central scotoma which has been described, there are others in which 
careful examination fails to show the presence of a scotoma, contraction 
of the field, or of retinal changes (Cohn, Schmidt-Rimpler). Hemianopsia 
may be present alone or with other cerebral symptoms. The pathologic 
change which is responsible for this condition is undoubtedly a lesion of 
the papillo-macular bundle of optic-nerve fibres. Microscopic examina¬ 
tions by Edmunds and Nettleship, Schmidt-Rimpler, Grosz, and others 
have confirmed this opinion. 

The prognosis of diabetic amaurosis concerns the continuance of the 
condition and the life of the patient. In general terms it may be said 
that the prognosis is not unfavorable. Often a proper regulation of the 
diet and appropriate internal treatment will result in restoration of vision; 
but the prognosis is less favorable if there is great reduction of visual 
acuity and a large central scotoma. Hirschberg and Schirmer regard the 
prognosis as unfavorable, having seen such patients die within a year. 

The treatment will be that which is appropriate for the general con¬ 
dition of the patient, and is explained in works on the practice of medicine. 

If a diabetic patient is addicted to tobacco or alcohol, their use should 
be discontinued and full doses of strychnin should be given. 

Amblyopia from Hemorrhage.—Temporary amblyopia or permanent 
loss of vision may follow a severe hemorrhage from any one of several 
organs. Fries collected 106 cases of visual disturbance following hemor¬ 
rhage (36 per cent, from the stomach; 25 per cent, from the uterus; 7 
per cent, from the nose; 5 per cent, from accidental wounds; 25 per cent, 
from intentional loss of blood by venesection, leeching, or cupping). 
The affection, which is found more frequently after than before the 
fortieth year, is seen rarely in previously healthy individuals who are acci¬ 
dentally w r ounded ( e.g soldiers in battle). As a rule, both eyes are in- 


554 


MODERN OPHTHALMOLOGY. 


volved in about the same degree; in 10 to 15 per cent, only one eye is 
affected. When the condition is bilateral, it is rarely the case that one 
eye is entirely blind and the other only slightly affected. According to 
Pergens, blindness following hemorrhage from the stomach is twice as 
frequent in men as in women. The age of the youngest recorded case of 
amblyopia from hemorrhage was two years; the oldest patient was seventy- 
seven years of age. 

Symptoms.— The loss of vision may appear during or immediately 
after the hemorrhage or some days or weeks later. The patient may suffer 
a severe hemorrhage without visual disturbance, only to have the vision 
much reduced or entirely lost after a recurrence of the bleeding. In re¬ 
peated hemorrhages vision may become less with each attack, while some 
improvement or entire restoration is noticed during the intervals. In 
25 per cent, of all cases the loss of vision comes during or immediately after 
the hemorrhage (Groenouw). In 20 per cent, it appears within the first 
twelve; hours. If delayed, the loss is noticed generally between the third 
and the sixth days, but may not appear until a period of two or three weeks 
has elapsed. In cases of severe hemorrhage, leading to unconsciousness, 
the patient on awakening will notice the blindness or may think that he 
is in the dark: i.e., that it is night-time. Cerebral symptoms—such as 
headache, syncope, exhaustion, cardiac palpitation, and severe pain in the 
back of the neck and about the base of the skull—are often present. 

The external appearance of the eye is nearly normal. In complete 
blindness the pupils are dilated and do not react to light. If the blind¬ 
ness is unilateral, the pupil of the affected eye will react synergistic with that 
of the normal eye. 

The ophthalmoscopic appearance will vary with the time of examina¬ 
tion. In the few cases which have been examined immediately after the 
advent of blindness the papilla has presented washed borders, slight swell¬ 
ing, with a surrounding area of slight opacity, which extends into the 
retina as far as the macular region and gradually diminishes peripherally. 
Small, brilliant spots also have been seen in the retina. In the majority 
of cases the ophthalmoscopic condition is either normal or negative. 
Ulrich in some cases saw the papilla pale, the arteries small, and the veins 
somewhat full. On the papilla itself the veins were narrow and of a bright- 
red color. Retinal hemorrhages were present. 

In unfavorable cases, in which the result is atrophy of the optic nerve, 
the papilla appears white; the arteries are narrow. This is the usual con¬ 
dition in patients who were first examined long after the advent of am¬ 
blyopia. The changes in the eyeground and the nerve-atrophy due thereto 
may be partial. Often good visual acuity will exist in spite of the presence 
of a white color of the optic nerve. At all events, the result of the ophthal¬ 
moscopic examination does not correspond with the degree of loss of 
vision; in spite of pronounced fundus changes, good visual acuity may be 
present, and vice versa. 


DISEASES OF THE OPTIC NERVE. 


555 


The visual field generally shows contraction, yet its form is scarcely 
characteristic; there is slight concentric narrowing. Often pronounced 
hemianopic forms are present, or a quadrant is wanting in the upper or 
lower half of the field. Uhthoff saw a case in which only the nasal half of 
the field was preserved, the color-fields for blue and red were much con¬ 
tracted, and in the blind temporal half two small islands were functionating. 
Central scotoma with normal peripheral field was noticed by Mandelstamm 
and Schmidt-Rimpler. The defect may exist only for colors or an absolute 
central scotoma may be permanently present. In the cured or improved 
cases there are generally defects in the visual field; rarely does the field 
become entirely normal. 

%j 

The light-sense has been but little examined. Pergens found it 
completely abolished. The central and peripheral color-sense is often 
materially lost, yet it may be normal or there may be narrowing of the 
color-fields. 

Retrobulbar neuritis with central scotoma was seen by Uhthoff in two 
women. Borsch observed it in a man with severe gastric hemorrhage. 

Pathogenesis. —A few of the hypotheses which have been advanced to 
account for the condition are: hemorrhage into the optic-nerve sheath (von 
G-raefe, Leber); stasis,in the retinal veins (Ulrich); thrombosis of the 
central retinal artery (Theobald) ; inflammation of the optic nerve with 
subsequent atrophy (Hortsmann and Hirschberg). The blindness which 
immediately follows hemorrhage is due to anemia of the brain (Fries). 
According to Samelsohn, complete amaurosis with retention of the pupillary 
reflex is caused by a lesion, probably an edema, of the visual centres. It 
is probable that the pathologic change may be either cerebral, neural, or 
retinal. 

Pathology. —Few examinations have been made of the eye and its 
adnexa after loss of vision from hemorrhage. Hirschberg found atrophy 
of the optic nerves, in a patient who had lost the vision of the right eye and 
retained vision of 1 / 2 in the left, after hematemesis occurring three and 
one-half years previously. The atrophy was complete in the right nerve 
and partial in the left. Ziegler found fatty degeneration of the optic 
nerve and retina. The examination was made twenty-three days after 
blindness from hematemesis. In the case of a woman aged 23 vears, who 
became blind on the second day after severe hemorrhage during parturition, 
and died from edema of the brain eight weeks later, Raehlmann found 
the lumen of the retinal arteries much diminished from endarteritis fibrosa. 
A similar change was present in the veins. Holden’s experiments on dogs 
and rabbits showed degeneration of the ganglion-cells of the retina, in¬ 
cluding their long processes, which form the centripetal fibres of the 
optic nerve. 

Prognosis. —The duration of the amblyopia varies from a few minutes 
to several hours. In most patients the improvement, if it occurs, appears 
after several days, weeks, or months. In almost 50 per cent, of cases 


556 


MODERN OPHTHALMOLOGY. 


there is not any improvement in vision; in 33 per cent, there is some 
restoration; and in 20 per cent, there is complete recovery of central, with¬ 
out entire restoration of peripheral, vision (Groenouw). Pergens, who 
has reported the visual result in 50 cases of hemorrhage from the stomach, 
states that the result was death in 6 per cent., blindness of both eyes in 36 
per cent., blindness of one eye in 18 per cent., great reduction of visual 
acuity in 14 per cent., and cure in 8 per cent. Eecoverv is possible even 
after perception of light has been abolished for several days, provided the 
pupillary reaction to light is retained. The date of the appearance of the 
blindness has no bearing on the prognosis. There seems to be no relation¬ 
ship between the amount of blood lost and the degree of improvement of 
vision. 

Treatment seems to be of hut very little value. A nutritious diet, 

rest, and the use of iron and strychnin are the most approved measures. 

Paracentesis of the anterior chamber and iridectomv are not to he com- 

•/ 

mended. 

Simulated Amblyopia (Pretended Amblyopia; Malingering).—Plain¬ 
tiffs seeking damages, men desiring to avoid military duty, and other per¬ 
sons may claim the existence of blindness of one or of both eyes. An' 
existing defect may be exaggerated. Atropin may be used secretly to assist 
in carrying out the deception. Intentional injuries of the eyes may be 
inflicted for the purpose of exciting sympathy or to avoid conscription. 
Generally the malingerer pretends that only one eye is involved. The tests 
which are designed for the exposure of such a case are described in Chapter 
IV (page 151). If blindness of both eyes is simulated only careful observa¬ 
tion of the patient over a prolonged period will expose the deception. An 
attempt should be made to watch the patient secretly. 

Nyctalopia (Functional Night-blindness).—In this affection the sensi¬ 
bility of the retina to light is diminished. It occurs suddenly in debilitated 
subjects after exposure to bright sunlight. Central vision is obscured, the 
patient seeing as through a cloud. According to Ivrienes, the accompany¬ 
ing symptoms are contraction of the field for white, reduction in central 
quantitative color-vision, dread of light, undue dilation of the pupils under 
reduced illumination, paresis of accommodation, erythropsia, xanthopsia, 
and epithelial xerosis. 

“Nyctalopia has been observed endemically among malarial subjects, 
scorbutic sailors, and among children in the public schools” (Snell). It 
has been found among Russians who have fasted during Lent, and among 
persons who have been deprived of proper food. It occurs chiefly in the 
springtime. Sleeping in the moonlight is said to be a cause. Nyctalopic 
patients see poorly on dark days and well on bright ones. The affection 
accompanies xerosis, and is found in some retinal and chorioidal diseases. 

Prognosis is favorable. The affection often disappears after several 
weeks or months. It tends, however, to return in the spring or summer of 
the following year. 


DISEASES OF THE OPTIC NERVE. 


557 


Treatment. —It has long been the belief of the laity that the ingestion 
of the liver of the sheep will cure night-blindness. This opinion has been 
confirmed by scientific observers. The patient should ingest from 6 to 8 
ounces of the liver of the goat, sheep, or ox, three times a day. The liver 
is to be fried in oil and is seasoned with spices. Buchanan, who treated 
twenty cases in this manner, states that five or six days are sufficient to 
effect a cure. Under ordinary tonic treatment such cases are not improved 
for several months. The liver treatment should be followed by a course of 
codliver-oil and ferruginous tonics. The night-blindness of retinitis pig¬ 
mentosa is not improved by this treatment. 

Hemeralopia (Day-blindness). —Hemeralopic patients see better on 
dark than on bright days. The same state of affairs is true of patients 
suffering with toxic amblyopia. Hemeralopia occurs in persons who have 
been long removed from light, and in those who have congenital defects, 
such as albinism, irideremia, coloboma of the chorioid, coloboma of the 
iris, etc. It is said to be congenital and to be associated with congenital 
amblyopia. Hemeralopia may be caused by exposure to bright light, such 
as reflection from snow and ice. Eyestrain from errors of refraction is 
said to be a cause. Photophobia and dazzling sensations are annoying 
symptoms. 

Treatment will include the correction of errors of refraction or of 
muscle-balance, the use of smoked glasses, and the administration of tonics. 
The patient should be instructed gradually to become accustomed to bright 
light. 

Scotoma Scmtillans (Amaurosis Partialis Fug-ax; Teichopsia; Flim- 
merskotom) .—These terms are applied to an amblyopia of central origin. 
The patient while suffering with vertigo notices before the eyes a bright 
light, which rapidly increases until finally he can scarcely see. Some pa¬ 
tients describe the first appearance as that of a small spot situated near the 
fixation-point. Within the area of this spot objects become invisible. The 
scintillating area spreads rapidly. It seems to be formed with flickering 
points arranged in a zigzag manner. The amaurosis disappears in from 
fifteen to thirty minutes, and is succeeded by nausea, vomiting, and head¬ 
ache (migraine). The affection is bilateral, and often involves but one- 
half of the visual field (the homonymous half). 

Scintillating scotoma is supposed to depend on circulatory disturbances 
in the occipital lobes. When occurring at long intervals it has no signifi¬ 
cance; if often present it may indicate impending cerebral lesions. Thus 
it may precede hemianesthesia, hemiplegia, brain tumor, apoplexy, and 
bulbar lesions. In some cases it is due to cerebral anemia. Swanzy states 
that fatigue, long reading, and hunger may cause it. It is not infrequent 
among physicians and other brain-workers. 

Treatment will include a cessation of brain-work, the use of alcoholics 
in moderation, the securing of sufficient sleep, and the taking of appro¬ 
priate exercise. Quinin, bromid of potassium, caffein, and strychnin have 


558 


MODERN OPHTHALMOLOGY. 


been used. Xeustiitter advises the administration of validol in 20-drop 
doses. 

Snow-blindness.'—Exposure to blinding reflections of the sun produces 
a variety of changes in the conjunctiva (hyperemia and edema), dendri¬ 
form ulceration of the cornea, contraction of the iris, and alterations in the 
retina (see page 514). Photophobia, blepharospasm, and lacrimation are 
early and annoying symptoms. Temporary or even permanent amblyopia 
may accompany the disease. Generally the symptoms disappear rapidly, 
the affection lasting only a few days. A scotoma may be present, with or 
without peripheric limitation of the field of vision. Reflection from snow 
may cause night-blindness. In the absence of sunlight erythema of the 
conjunctiva may be produced by the impact of flying particles of ice or of 
snow. Exposure to the x-ray and to electric flashes may cause similar 
symptoms. The treatment of snow-blindness includes removal of the cause, 
protection of the eyes by means of smoked glasses, the use of atropin and 
hot applications, and the instillation of a weak solution of argyrol. 

Hemianopsia (Half-sight) is discussed in Chapter XXII. 

Reflex Amblyopia.—This term has been applied to cases in which loss 
of vision is supposed to be due to reflex irritation. The condition has been 
attributed to intestinal parasites, to decayed teeth, and to diseases of the 
naso-pharynx, uterus, or ovaries. If caused by carious teeth the amblyopia 
will be unilateral or, if bilateral, will be greater on the side of the dental 
disease. Vision may be slightly reduced or may be limited to perception of 
light. Removal of the source of irritation is followed by recovery of visual 
acuity. 

Hysteric Amblyopia occurs in both sexes, but is more frequent in neu¬ 
rotic females. It is usually associated with other signs of hysteria. As a 
rule, but one eye is affected and the loss of vision is complete. Usually the 
pupil reacts to light. In some cases the pupillary reaction is abolished 
temporarily— i.e., the pupil is dilated and immobile. In cases of less sever¬ 
ity there may be a central scotoma and partial color-blindness. Perimetric 
examination of such subjects will often show the field for red and green fo 
be larger than that for white. Complete reversal of the color-fields has been 
noted. Ophthalmoscopic examination shows nothing abnormal. Concom¬ 
itant hysteric symptoms are hemianesthesia, loss of various (pharyngeal, 
corneal) reflexes, blepharospasm, ptosis, monocular diplopia, micropsia and 
megalopsia, conjugate deviation of the eyes, and the symptom-complex called 
“retinal asthenopia.” 

Diagnosis may be difficult. Symptoms which are attributed to hys¬ 
teric amblyopia may long precede the advent of serious cerebral disease 
(Friedenwald). 

Prognosis is ultimately favorable, although the amblyopia may persist 
for weeks or months. 

Treatment will include suggestion, tonics, rest, massage, electricity, 


etc. 


DISEASES OF THE OPTTO NERVE. 


559 


Colored Vision.—Reel vision, erythropsia, occurs not infrequently after 
cataract extraction, particularly in patients who neglect to wear smoked 
glasses for several weeks after the operation. Erythropsia has also been 
observed in persons who have had no operation or inflammation of the eyes. 
In such cases it is attributed to exposure to intense light or to irritation of 
the cortical visual centres. The use of coffee may cause red vision. It 

%J 

sometimes follows fasting and fatigue due to excessive near work. It is not 
uncommon among neurotic school-children. Blue vision, cyanopsia, occa¬ 
sionally appears after cataract extraction, and is attributed to the diffusion 
of light caused by thin layers of cortical substance which remain in the 
pupillar}' area (Becker). With the absorption of the cortical masses the 
blue vision disappears. It also occurs in overworked, nervous subjects. 
Yellow vision, xanthopsia, is a symptom occurring in santonin poisoning, 
and is noticed by patients who are suffering with glaucoma and optic-nerve 
atrophy. Green vision has been noted by Dodd, who collected 13 cases. 
One of these followed cataract extraction, 1 was sequent to a wound, and 8 
suffered with diseases of the optic nerve, retina, and chorioid. In 2 cases 
the green vision was noticed only when the patients were indoors. In 
glaucoma the patient may complain of variously colored halos around lamp¬ 
lights. Persons with blind eyes tell of phosphene-experiences which are 
probably due to an irritation of the visual centres. 

Treatment.— Bromids, iodids, pulsatilla, and gelsemium have been 
recommended. 

Malarial Amblyopia.—Transient amblyopia may occur in persons who 
are suffering with malaria. The pupils are widely dilated and vision is lost. 
Fundus changes are absent and vision returns after the administration of 
quinin and other appropriate remedies. 

Micropsia, Megalopsia, and Metamorphopsia.—Objects may appear too 
small, micropsia; too large, megalopsia ; or distorted, metamorphopsia. 

These symptoms may be complained of in hysteria, or may exist in any 
condition which causes a separation or an approximation of the retinal ele¬ 
ments (rods and cones). Syphilitic chorioidoretinitis is a frequent cause of 
micropsia and megalopsia. After the correction of a refraction-error of 
high degree the patient may complain that objects are too small, too large, or 
are distorted. 

Benson lias recorded a case of monocular micropsia, which was at¬ 
tributed to weakness of the accommodation from an attack of diphtheria. 
The micropsia and megalopsia of hysteria are attributed by Parinaud to 
spasm of the accommodation. 

Dudley has reported the cases of three middle-aged men, each of whom 
complained of (right) monocular metamorphopsia various: i.e., the distor¬ 
tion of the object viewed was constantly changing (see Fig. 338). Since 
refraction and retinal changes did not exist, he concluded that the cause 
must be mental. Savage believes that the condition depends on retinal 
changes which are too minute to be visible ophtbalmoscopically. 


560 


MODERN OPHTHALMOLOGY. 


INJURIES OF THE OPTIC NERVE. 

Not infrequently the optic nerve is injured by fracture of the walls of 
the optic foramen. Other injuries are of rare occurrence. They include 
stabs with knives, the tips of umbrellas, penetration of the orbit by splinters 
of wood or of metal, injuries by flying pieces of metal, etc. The author 
has seen two cases in which attempts to commit suicide by the use of a pistol 
resulted in the division of both optic nerves without the production of 
injuries sufficient to cause death. Early in such a case the optic papilla 
will be swollen, resembling the papillitis of brain tumor. A partial division 
of the optic nerve is said to be followed by complete atrophy. 



1 

o 

□ 

<0 


L L Ii 


nm 

t? 9 o o o 

EJU £\ OH DO. 

o oq 


Fig. 338.—Metamorphopsia varians. (Dudley.) 

The test-objects are placed at the left of the vertical line ; the figures at the right show the 

varying distortions. 


OPERATIONS ON THE OPTIC NERVE. 

Section of the optic nerve is a necessary part of the operation for 
removal (enucleation) of the eyeball. After this has been accomplished 
many surgeons perform resection of the nerve, cutting it as close to the optic 
foramen as possible. Kesection of the nerve with preservation of the globe 
is a part of the procedure known as Kronlein’s operation, and is described 
in Chapter XIX. In Hall’s operation (eviscero-neurectomy) a small part 
of the sclera adjacent to the nerve-head and a portion of the nerve-trunk 
are removed (see Chapter XANII). In this place it is necessary to men¬ 
tion two operations in which, although other structures are severed, the 
primary object is to sever or to excise the optic nerve. 





DISEASES OF THE OPTIC NERVE. 


5G1 


Opticociliary Neurotomy was proposed by Boucheron in 1890. Under 
general anesthesia, the internal rectus muscle is exposed and is secured by 
passing a suture through it at a point about ten millimetres behind the 
cornea. The muscle is then cut anterior to the suture. The optic and 
ciliary nerves are then cut. The muscle is sutured and a compress bandage 
is applied. This operation has been superseded bv 

Opticociliary Neurectomy.— This operation includes section of the in¬ 
ternal rectus muscle, division of the optic and ciliary nerves close to the 
optic foramen, and excision of the optic nerve. In order to accomplish the 
excision the globe must be turned so that its posterior part becomes visible. 
The eyeball is replaced, the muscle is sutured, and a bandage is applied. 

Value of these Procedures. —Opticociliary neurotomy and neurectomy 
were proposed for the purpose of preventing sympathetic ophthalmitis. 
They are not sure means of prophylaxis, several cases having been reported 
in which sympathetic inflammation occurred long after the operation had 
been performed. For the prevention of sympathetic ophthalmitis neurot¬ 
omy ranks far below enucleation, evisceration, or neurectomy. Since re¬ 
generation of the nerves occurs, opticociliary neurectomy is not a sure 
means of preventing sympathetic disease. 


CHAPTER XVII. 


GLAUCOMA. 

NORMAL INTRA=OCULAR TENSION. 

Within the eye are three kinds of fluid: blood from the blood-vessels; 
lymph, which is present in the lymph-spaces of the uveal tract and peri¬ 
vascular lymph-channels, its amount depending on the blood-pressure; and 
the intra-ocular fluid, which is a secretion of the epithelium covering the 
ciliar}^ body and is found in the aqueous and vitreous chambers. The 
intra-ocular fluids obtain exit in various ways. The major portion escapes 
via the anterior chamber, the spaces of Fontana, the canal of Schlemm, and 
thence into the anterior ciliary veins (Leber). A portion escapes via 
openings on the anterior surface of the iris and thence into the iridal veins 
by filtration (Nuel). A small part passes into the vitreous humor and 
escapes via the lymph-spaces which surround the central retinal vessels. 
The normal intra-ocular fluid (aqueous and vitreous humors) is composed of 
99 per cent, water, 1 per cent, salts and extractives, with a trace of albumin. 
Filtration of such fluid can occur readily. If the albumin is increased in 
quantity, as occurs in glaucoma, filtration becomes more difficult. 

Normal pressure within the eye is equal to a column of mercury 26 to 
28 millimetres in height, varying with race, age, and altitude. Uniformity 
of pressure is maintained by a nervous mechanism which is not thoroughly 
understood. The sympathetic nerve has a potent influence upon intra¬ 
ocular tension. Stimulation of the cervical portion of this nerve causes 
dilation of the pupil, increased blood-pressure, increased secretion from 
the ciliary body, and contraction of Muller’s muscular fibres. Excision 
of the superior cervical ganglion of the sympathetic nerve causes an oppo¬ 
site effect, viz.: contraction of the pupil, decreased blood-pressure, dimin¬ 
ished secretion from the ciliary body, and relaxation of Muller’s fibres. 
Dividing or irritating the trigeminal nerve in animals has lead to contra¬ 
dictory results. Donders found that division of the nerve produced lowered 
tension, while its irritation was followed by increased intra-ocular pressure. 
Wegner found that similar experiments gave negative results. 


GLAUCOMA: GENERAL CONSIDERATIONS. 

Glaucoma has been defined as increased intra-ocular pressure plus the 
causes and results of such pressure. This definition, which is credited to 
Priestley Smith, leaves much to be desired. The signs of glaucoma are 
well known. Its effects upon the ocular structures and functions are thor¬ 
oughly understood. The limits of its therapeusis are painfully apparent, 
(562) 


PLATE XXIII, 

Eiisaasas of the Optic .Narva i 


Fig. 1.—Papillitis, 


Fig. 2.—Glaucoma, 


Bfeucami 



. 

.IIT.XX 3T Kd^L 

.^rnoaxiBia .evisKI oitqa erff lo bbbbbbIII 


CHAPTER XVH. 


u 

GLAUCOMA. 

NORMAL INTRAOCULAR TENSION. 







. v.resenr m dm lymph-tpactt of the uveal tract and peri- 
'•l. it® ae ; f on theblood-pressure; and 

.t iBrc>f the .’pAhol am covering the 
• me i;t in th< niueous and vitieous chambers. The 

• * . • ;i >• • -v iv. The major portion escapes 

- i - - J'mtana. the can a : of Eehlerrun, and 
•r • . . i i : i. r; . A i-o"tiou escapes \i.t 

i. ;r --! »<:■< of the iris and thence into the rridal veins 

/ 

\ -•<•:»!.} part passe? into the vitreous hmnor and 
v ich surround the central ret oat vessels, 
u iUpjeouB and vitreous humors) is composed of 
L- ! i • 1 o." p.-r (> m -tips and extractives, with a trace of albumin. 

Ally. If the albumin is increased in 
rt ! -m becomes more difficult. 

•: « o uni li a column of mercury 26 to 
t j y th iH • *, a.:?-, and altitude. Uniformity 
: ' c- ■mchamsin which' is not thoroughly 

■ .■ «>cr ( f'l- a \x dealt influence upon intra- 
:-i cm • il -portion of this nerve cau-o.- 

Uoo* pre-sere, mcreased secretion fr«>m 
l. ts i-\ - uhv-' mu of Muller's muscular fibres. Excision 

Vi - *, .on of tit • ‘Vopaihetic nerve causes an oppo- 

i pupil; decreased Mood-pressure, dimin- 
. ■ ■ ■• body, and relaxation of Midler's fibres. 

nerve in animals has lead to contra- 
1 \ ion • ? the nerve produced lowered 

.BinnauEia-,S -S^ 

. : ’ ■ i by increased intra-ocular pressure. 

’ . ■ t.. , ' . -'.o ; . ,",o gave negative results. 


i'ii * .D' i \. »|f M5R 


Considerations. 

. - intra-ocular pressure plus the 
a ion, which is credited to 
i -sigHf of glaucoma are 
and functions are thor- 
' painfully apparent. 


PLATE 23 









GLAUCOMA. 


563 


but the real cause of the disease is unknown. Except for those cases in 
which increased tension is due to changes in other parts of the eye,—viz.: 
secondary glaucoma,—the ophthalmologists of to-day have been until re¬ 
cently almost as much in the dark as to its etiology as were those of fifty 
years ago. Recent investigations have shown that under the name glaucoma 
are included several different diseases. Late observations indicate that 
changes in the sympathetic nervous system have much to do with the pro¬ 
duction of idiopathic glaucoma. The author believes that primary glaucoma 
should be defined as a disease of the sympathetic nervous system producing 
increased intra-ocular pressure. 

Glaucoma may be congenital or acquired, primary or secondary to some 
other disease, acute or chronic, inflammatory or simple. Always, however, 
it is a progressive disease, and tends to destroy vision. It may begin with 
hemorrhages from the retinal vessels, or these may never rupture, or the 
glaucomatous process may last for a long period and the hemorrhages 
appear in the last act of the drama. The subject will be considered under 
the following heads: (1) glaucoma simplex, (2) chronic irritative glau¬ 
coma, (3) acute inflammatory glaucoma, (4) hemorrhagic glaucoma, and 
(5) secondary glaucoma. These divisions, while necessary for teaching 
purposes, are somewhat arbitrary, since all sorts of gradations exist. Thus, 
a case of glaucoma simplex, after a long period, may end in an attack of 
the acute inflammatory type and be followed by hemorrhages into the eye. 

Etiology. —Glaucoma is chiefly a disease of advanced life. The lia¬ 
bility of females is greater than that of males in the ratio of six to five. At 
the age of 65 years the liability to an attack of glaucoma is twice as great 
as at 45 j^ears, and 100 times as great as at 15 j^ears (Priestley Smith). 
The liability of advanced life is thought by Priestley Smith to be due to 
the growth of the lens. While the cornea attains its maximum diameter 
about the fifth year, and the globe is of full size at the twentieth year, the 
lens continues to grow from youth to old age. During the period between 
25 and 65 years it adds one-tenth to its diameter and one-third to its 
volume (Priestley Smith). The lens, pressing against the ciliary processes, 
causes the base of the iris to encroach on the filtration angle, and thus excre¬ 
tion of aqueous humor is hindered. Small eyes are especially liable to 
primary glaucoma. An eye with a small cornea and an antero-posterior 
diameter 1 or 1.50 millimetres less than the normal is very likely to become 
glaucomatous. Heredity would seem to be a factor only when associated 
with congenital smallness of the globe. Certain races seem more liable to 
glaucoma than others. It is said that the disease is particularly frequent 
among Egyptians and Jews and among the negroes of Brazil. The influ¬ 
ence of hypermetropia and accommodative strain seems undoubted. Mydri- 
atics—such as atropin, scopolamin, cocain, homatropin, and euphthalmin— 
have been known to cause glaucoma in eyes previously presenting no sign 
of disease. When the filtration angle is already small, the folding and 
thickening of the iris, which are produced by the mydriatic, will cause a 


564 


MODERN OPHTHALMOLOGY. 


further blocking, and glaucoma results. Congestion of the uveal tract is a 
factor. Many cases can be traced to exposure, bronchitis, cold in the head, 
heart disease, hepatic derangements, constipation, all of which are condi¬ 
tions in which the venous system is engorged. It is a common observation 
that a patient with glaucoma feels much better and his eye looks better after 
the alimentary tract has been emptied. Grief, anxiety, worry, and the loss 
of sleep are direct causes of primary glaucoma. Operation on one eye is 
often followed by an attack of glaucoma in the other eye. Slight local 
injury, such as an abrasion of the cornea, may cause a glaucomatous attack. 



Fig. 339.—Section of normal superior cervical ganglion. (Author.) 

(Original drawing by Dr. Caul Fisch.) 

1 , Artery. 2 , Capillary. 8 , Nerve-process. 4, Medullated fibres. 5 , Bundle of nerve-fibres. 

6 , Bundles of non-medullated fibres cut across. 7, Nerve-cell. 

(Reitz : ocular 4, objective 6.) 

Certain cases of glaucoma must be attributed to disease of the blood¬ 
vessels leading to thrombosis, hemorrhage, or exudation. 

Finally, the sympathetic nervous system has much to do with the pro¬ 
duction of glaucoma. This view is suggested by the fact that, in the cases 
in which the author removed the superior cervical sympathetic ganglia for 
the cure of glaucoma, the microscope showed marked pathologic changes. 
Laqueur noticed that the exciting causes of mild attacks in the so-called 
premonitory stage of glaucoma are conditions of nervous depression (cold, 
hunger, fatigue, fright, anger, sleeplessness, etc.) which are associated with 








GLAUCOMA. 


565 


dilation of the pupil, while the conditions under which these premonitory 
attacks disappear (warmth, food, sleep) produce contraction of the pupil. 

Pathology. The pathologic changes in glaucoma are found in the 
cervical portion of the sympathetic nerve, in the tissues of the eye, and in 
the intra-ocular contents. 

Changes in the Sympathetic Nerve.— Microscopic sections of the 
superior cervical ganglion of the sympathetic nerve show a marked hyper¬ 
plasia of connective tissue, which often results in the division of the gan¬ 
glion into small groups of nervous elements separated by broad bands of 
fibrous elements-. The vails of the blood-vessels show sclerosis. The 
connective-tissue sheaths of the ganglionic cells are much thickened, and an 
infiltration of small round cells is present in the hyperplastic tissue. 



Fig. 340. Angle of the anterior chamber of a normal eye. (Author.) 

(Photomicrograph by Dr. H. P. Wells.) 

The ganglionic cells are markedly pigmented. Together with a num¬ 
ber of cells normal to all appearance there are great numbers showing 
different stages of degeneration. As a rule, the nucleus, besides losing part 
of its peculiar staining property, assumes the parietal position. The 
nucleus is reduced in size or even missing in a large percentage of the cells. 
While in some cells the chromatic elements are well preserved, in others 
the process of chromatorrhexis and chromatolvsis can be followed through 
all of the stages. Only comparatively few cells are seen showing the nor¬ 
mal dendriform processes. Often the processes are short, ending bluntly, 
or even disappearing altogether. The general peripheral network of proc¬ 
esses is much reduced in volume and compressed by the pressure of the 
connective-tissue formation. Only very few medullated fibres are seen. 


5G6 


MODERN OPHTHALMOLOGY. 


The general pathologic aspect is that of a decided sclerosis, originating 
in inflammatory processes going on in, and starting out from, the walls 
of the vascular structures. The changes of the nervous elements may not 
be idiopathic, but are probably due to pressure and inhibited nutrition. 
While these changes are suggestive of the sympathetic origin of glaucoma, 
it must be acknowledged that similar pathologic lesions of the sympathetic 
nerve exist in optic-nerve atrophy and in exophthalmic goitre. 

The Macroscopic Changes in the Eyeball are chiefly a blocking 
of the angle of filtration and an excavation of the head of the optic nerve. 
These alterations can be accounted for by the theory that pathologic changes 
in the sympathetic nerve cause increased intra-ocular pressure. In response 



Fig. 341.—Angle of the anterior chamber of a glaucomatous eye. (Author.) 

(Photomicrograph by Du. H. P. Wells.) 

to hypertonia, the lens is pushed forward, and the iris becomes adherent 
at its periphery to the cornea. The escape of the aqueous humor is hin¬ 
dered; the optic-nerve entrance, being the weakest part of the globe, is 
pushed backward. The escape of blood through the veins of the chorioid is 
interfered with, by contraction of the unstriped peribulbar muscular fibres, 
which are found in the capsule of Tenon. It is probable that the diseased 
sympathetic causes an increase in the secretion of the aqueous humor. Thus, 
increased secretion, on the one hand, and diminished excretion, on the 
other, bring about a condition which ends in the complete disorganization of 
all of the ocular structures. That this is a reasonable hypothesis is proven 
by the fact that, if the changes have not progressed too far,— i.e ., if the 
root of the iris is not too firmly fastened to the cornea,—excision of the 



GLAUCOMA. 


567 

sympathetic nerve will cause a diminution of tension, a contraction of the 
pupil, and an improvement in the intra-ocular circulation. 

The Anatomic Changes in Glaucomatous Eyes are*alf due to in- 
ciease of tension. The venae vorticosas being compressed easily, because of 
their oblique course through the sclera, the venous blood from the uveal 
tiact passes from the eye in large part through the anterior ciliary veins, 
uhicli become enlarged and tortuous. In acute inflammatory glaucoma 
the uveal tract is the seat of inflammatory edema. Synechias are rare, and 
exudations of magnitude are never seen. The cloudiness of the cornea is 
not a true inflammation, but an edema. The iris is similarly affected, as 
ib shown by discoloration and swelling. In response to pressure the lens 
mo\es forward, decreasing the depth of the anterior chamber; and swelling 
of' the ciliary processes results in the approximation of the iris-base to the 
periphery of the cornea, as shown in Fig. 341. Compression of the ciliary 
nenes causes loss of sensation in the cornea and dilation of the pupil, with 
paralysis of the iris, the pain of glaucoma comes from the compression 
of nerve-filaments in the ciliary body and iris. Loss of vision is due to 
thiee lesults of pressure: (1) the opacity of the cornea, explained above; 
(~) ischemia of the retina, due to pressure, contracts the visual field; and 
(o) pressure on the optic-nerve fibres causes atrophy. In glaucoma sim¬ 
plex loss of vision is due chiefly to excavation and to atrophy of the nerve. 

It is now necessary to consider more explicitly the effects of increased 
intra-ocular tension upon the various structures of the eye and their re¬ 
spective functions. The eyelids in acute cases may show edema. The 
conjunctiva shows general hyperemia, and in acute types it becomes edema¬ 
tous (chemosis). It is of a dusky color. The anterior ciliary veins , which 
normally gne exit to a small part of the blood from the uveal tract, in 
glaucoma are much enlarged by reason of the blocking of the veme vorticosse 
through which normally the major portion of the blood from the uveal 
tract passes from the eye. The anterior ciliary arteries become hypertrophic 
in cases in which the increase of tension is of long duration. If increase of 
tension occurs slowly the vascular chauges are slight. The sclera becomes 
distended in the glaucoma of childhood (hydrophthalmos). In adults it 
is a fixed and unyielding structure. In eyes which have long been glau¬ 
comatous there is a separation of the scleral bundles. The cornea becomes 
edematous. Microscopic examination shows spaces between the epithelial 
and anterior elastic layers as well as between the epithelial cells. The 
spaces between the anterior layers of the lamellse are distended with albumin¬ 
ous fluid. These changes are apparent clinically as a superficial haziness 
which rapidly disappears when the intra-ocular tension is lowered. Vesicles 
may form on the surface of the cornea. The haziness causes the patient to 
complain of the appearance of a halo around lights. Anesthesia of the 
cornea is a common symptom in glaucoma, and is attributed to compression 
of nerve-fibres either in the cornea or on the long ciliary nerves lyino- i n 
their scleral grooves. 


568 


MODERN OPHTHALMOLOGY. 


The anterior chamber in primary glaucoma is shallow from pressure in 
the vitreous chamber forcing the lens forward. In congenital glaucoma, 
as well as in' some secondary cases, the iris is primarily adherent at its 
periphery to the posterior surface of the cornea, thus blocking the angle 
of filtration. In such an event the anterior chamber becomes deepened. 
The iris, in recent cases, is pressed against the posterior surface of the 
cornea. Thus, the iridal vessels and nerves are compressed. If the increase 
of intra-ocular tension comes suddenly, the iris shows edema, venous en¬ 
gorgement, and change in color. At a later period it undergoes atrophy. 
The vessels are emptied, become sclerotic, and undergo hyalin degeneration. 
The stroma disappears and the uveal pigment projects into the pupillary 
area (ectropion uvese). In acute glaucoma the pupil is dilated, pressure 
causing loss of function in the sphincter muscle. If tension is relieved 
by an early operation, the function is restored. In old cases of glaucoma 
the pupil is permanently dilated. It may be round, but generally is some¬ 
what oval. Adhesions between the iris and cornea can be readily separated 
in recent cases. In old ones the iris shows exudation, small-cell infiltra¬ 
tion, and firm adhesion to the cornea. In glaucoma simplex there is often 
an absence of dilation of the pupil and an absence of atrophy of the iris. 

The effect of increased pressure upon the ciliary body is shown in the 
apparent rapid increase of presbyopia. The patient will accept stronger 
convex lenses for reading than his age warrants, and will add to the 
strength of his glasses at short intervals. In acute types of glaucoma the 
ciliary processes become swollen and edematous. They press against the 
peripheral portion of the iris. Later they become atrophic. In glaucoma 
simplex these changes are slight. In old cases the ciliary muscle becomes 
atrophic. Pain, which is due to compression of the nerve-fibres of the 
ciliary plexus by the edematous ciliary processes, is frequently present in 
acute types of the disease and is often referred to other branches of the 
trifacial nerve. If the increase of tension is but slight, or if it comes on 
slowly, as in glaucoma simplex, pain is either absent or is insignificant. 
Early in the history of a case of acute glaucoma the chorioid is edematous 
from venous obstruction; later it becomes atrophic. In the simple form 
of the disease the atrophy is less marked and is slow to appear. Such a 
case will often show a “tessellated fundus.” Atrophy of the chorioid 
around the optic disc is often seen in old cases of glaucoma. An area of 
sclera surrounding the disc is then exposed to view. In the equatorial 
region, where the venje vorticose obtain exit, the chorioid is often atrophic. 

The crystalline lens also suffers changes in glaucoma. In acute cases it 
is pushed forward and its refractive power is lessened. The effect is to make 
the emmetropic eye myopic. In old cases of glaucoma the lens becomes 
opaque (glaucomatous cataract), and appears of a bluish-white color with a 
silk-like lustre (Pig. 5, Plate XII). This form of cataract appears in eyes 
which are undergoing glaucomatous degeneration, and hence are blind. It is 
to be distinguished from that form of lenticular opacity which accidentally 


GLAUCOMA. 


5G9 


occurs in an eye which has glaucoma (cataract in a glaucomatous eye). It 
is evident that the latter condition may offer a favorable prognosis. Thus, 
the surgeon, in such a case, makes an iridectomy to reduce the intra-ocular 
tension and some weeks later extracts the lens. Traumatic cataract also 
may occur in an already glaucomatous eye. The intra-ocular fluids are 
altered in glaucoma, as will be explained in a succeeding paragraph. 

The retina suffers from increased intra-ocular tension, the first effect 
being an obstruction to the entrance of arterial and to the exit of venous 
blood. Arterial pulsation is either present or can be elicited by slight pres¬ 
sure made upon the globe through the intervening eyelid. Sclerosis of the 
vessels, with hyalin degeneration, and hemorrhages are not infrequent in 
glaucomatou'S eyes. The retina shows the effect of increased pressure by a 
disturbance of function or by atrophy. Loss of vision may appear sud¬ 
denly in acute glaucoma or it may develop slowly in the chronic form of the 
disease. So long as atrophy of retinal tissue has not taken place a restora¬ 
tion of vision is possible. Reduction in vision begins peripherally and is 
manifested as a contraction of the visual field, which is general!v first 
observed on the nasal side (temporal half of the retina). The arteries and 
nerve-fibres which pass to the temporal portion of the retina must run a 
greater distance than those which supply the nasal side. Hence the early 
loss in the nasal part of the visual field. The field may be concentrically 
contracted or irregularly lessened. Generally, the field assumes an oval 
shape with its chief area on the outer side of the point of fixation. There 
is usually commensurate loss of central visual acuity, but in glaucoma sim¬ 
plex there may be marked contraction of the visual field, with retention 
of normal central vision. In some cases there is a central or paracentral 
scotoma. The color-fields are generally contracted commensurately with 
the loss of the field for white. 

The optic nerve, which is swollen and edematous in the early stages 
of acute glaucoma, soon becomes excavated. The causes of the excavation 
are the retrocession of the lamina cribrosa and the atrophy of the nerve- 
fibres. The excavation involves the entire head of the nerve and may as¬ 
sume one of several shapes. A low grade of neuritis is often present in 
glaucoma, as is evidenced by the presence of round-cell infiltration in the 
optic nerve surrounding the excavation. The term anterior glaucoma is 
applied to those cases which show the chief alterations in the anterior ocular 
segment (adhesion of the iris to the cornea, closure of Schlemm’s canal, 
etc.), while the name posterior glaucoma indicates that the chief changes are 
to be found in the optic-nerve head and its vicinity. 

Changes in the Intra-ocular Contents. —Troncoso has shown that 
in glaucoma the composition of the aqueous humor is altered. Its density 
is increased. The quantity of mineral salts is greater than normal. Most 
striking is the increase in organic ingredients (albumin, etc.). This 
change in the amount of albumin present in the aqueous humor is attributed 
to vascular disturbance. A fluid which is loaded with albumin can be 


570 


MODERN OPHTHALMOLOGY. 


excreted only slowly and with difficulty. The quantity of aqueous humor 
is less in the glaucomatous than in the normal eye (Troncoso). 

Ophthalmoscopic Signs. —In glaucoma the ophthalmoscope shows a 
characteristic picture. The head of the nerve is excavated, the vessels are 
pushed toward the nasal side of the disc, and the edges of the disc often 
appear undercut (Fig. 2, Plate XXIII). This condition is shown by the 
bending of the vessels, which appear as if climbing over a ledge. The 
lamina cribrosa, being the weakest part of the eye, is bent backward and 
carries with it the vessels and nerve-fibres. The arteries become smaller 
than normal, the veins are engorged, and the nerye-fibres undergo atrophy. 
Usually the whole optic-nerve head is depressed, the excavation being com¬ 
plete, as shown in Fig. 343. Occasionally, in glaucoma simplex, the exca¬ 
vation is complete only on the temporal side of the disc, while the vessels 
on the nasal side are separated from the scleral ring by a narrow margin 
of nerve. 



Fig. 342.—Head of normal optic nerve. Fig. 343.—Head of optic nerve in glau* 
(Author.) coma absolutum. (Author.) 

As a result of retrocession of the lamina cribrosa producing atrophy, 
vision—central and peripheral—is reduced and finally lost. Peripheral 
vision is the first to suffer, owing to ischemia. The loss is manifested by 
a contraction of the form-field, which is either concentric or irregular. 
Often the limitation of the field begins on the nasal side, the temporal 
part of the nerve being the first to suffer. In glaucoma simplex it is not 
unusual to meet with a concentric contraction of the field. 

In making a diagnosis with the ophthalmoscope the observer must 
remember the anatomic peculiarities of different varieties of excavation: 
the physiologic, atrophic, and glaucomatous. A partial excavation is phys¬ 
iologic; a total one is pathologic. Of the latter, the excavation of 
atrophy is shallow, and slopes gradually. The excavation of glaucoma is 
shallow or deep according to the duration of increased pressure. In the 
shallow form the nerve-head retains a good color, while m the excavation 
of atrophy the papilla looks very white. If the excavation be deep and 
involve the whole disc, it can be due only to glaucoma. Atypical cases 



GLAUCOMA. 


571 


are sometimes seen in which only the temporal side of the disc is excavated; 
the vessels are pushed to the nasal side, being separated from the scleral 
ring by a band of healthy nerve-tissue. In myopic eyes in which glaucoma 
supervenes the picture may be atypical, and repeated examinations may be 
necessary to establish the diagnosis. 

In advanced glaucoma the whole nerve-head is deeply excavated and 
the papilla is of a bluish or greenish-white color. In the depths of the 
excavation the lamina cribrosa can be recognized by the presence of gray 
dots. By direct ophthalmoscopy the vessels cannot be traced from the 
centre of the nerve to the scleral ring, but by the indirect method they 
can be seen in their whole course. The direct method enables the observer 
approximately to measure the depth of the excavation. If the vessels, as they 


Fig. 344.—Types of excavation of the optic nerve. (Jexxixgs.) 

A, Physiologic excavation. B, Atrophic excavation. C, Glaucomatous excavation. 

climb over the ledge, are seen distinctly without a lens in the ophthalmo¬ 
scope, a concave lens will be necessary to see them distinctly at the bottom of 
the depression. Each dioptre represents a depth of 0.3 millimetre. Sup¬ 
pose, for example, the retinal vessels at the scleral ring are seen with a 
-j- 1 D. lens and the central vessels in the depressed nerve are visible clearly 
with a — ID. lens, the excavation would amount to 0.6 millimetre, the 
difference between the two glasses being 2 D. In using indirect ophthal¬ 
moscopy the difference in level between the scleral ring and the depressed 
nerve-head can be recognized only by parallactic displacement, the bottom 
of the excavation and the surrounding fundus seeming to move at different 
rates. The excavation moves more slowly than does the fundus. Thus the 
fundus seems to move over the disc. In old cases of glaucoma the papilla 



s‘V : ■* 




























572 


MODERN OPHTHALMOLOGY. 


is surrounded by a circle of atrophic chorioid—the so-called glaucomatous 
halo. 

The loss of sight does not depend so much on the depth of the excava¬ 
tion as on the extent to which atrophy of the nerve-fibres has taken place. 
It is not unusual to find that an eye with a deep excavation possesses con¬ 
siderable or possibly normal central vision. On the other hand, the vision 
may be lost completely in a few hours—as in glaucoma fulminans—without 
excavation, the period being too short for excavation to occur. The color of 
the papilla and the size of the retinal vessels form a better guide for judg¬ 
ment as to visual acuity than does the depth of the excavation. 

CLINICAL VARIETIES AND TREATMENT OF PRIMARY 

GLAUCOMA. 

Glaucoma Simplex—This disease comes so slowly and quietly that 
it is often overlooked. It may appear at any time between the thirteenth 
and ninety-sixth j^ears, although most cases develop during middle life. 
Few cases have been seen in children. The refraction is usually hyper¬ 
metropic, although exceptionally it may be myopic. Externally the eye 
may appear normal, or the sclera may be abnormally white and present a 
few tortuous vessels. The disease at first causes no pain, but only a feel¬ 
ing of heaviness in and around the eye. Central vision may be almost nor¬ 
mal, or normal one day and foggy (Y. = 20 / 40 or 20 / 30 ) the next. The field 
for form is somewhat contracted, and the color-field is narrowed in pro¬ 
portion. Tension is variable—normal at one time and slightly increased at 
the next examination. The anterior chamber may appear of normal depth 
and the pupil may be responsive to light. One eye only may be affected, 
in which case the corresponding pupil will be slightly larger than its fellow. 
Sometimes, during the period of fog, careful examination will show steami¬ 
ness of the cornea. So far as the symptoms referable to the front of the 
eye are concerned, it is impossible to make a diagnosis. The examiner 
must depend on the findings of the perimeter and particularly on those of 
the ophthalmoscope. 

For a long time in the history of a case of glaucoma simplex the media 
are clear and the optic nerve can be examined satisfactorily. The nerve- 
head may present the classic punched-out appearance, or the excavation 
may markedly resemble that of atrophy, except that in one part of the disc 
the excavation is very deep and extends to the periphery. The vessels are 
pushed to the nasal side, and they do not form continuous lines, but are 
broken in their course from the centre of the nerve to the edge of the disc. 
The veins may be normal or enlarged and dark. The arteries may or may 
not pulsate spontaneously. If they do not beat spontaneously, pulsation 
is readily elicited by slight pressure on the upper lid. In typical cases 
the diagnosis of glaucoma simplex can be made easily with the ophthalmo¬ 
scope, but atypical cases may puzzle the surgeon and may require repeated 
examinations. A map of the visual field is of importance. Central form- 



GLAUCOMA. 


573 


and color- vision are good, while the peripheral fields may be much con¬ 
tracted. The usual change of the form-field is a loss in the nasal portion; 
or there is concentric contraction; or sectional defects, especially in the 
uppei field, are found; or the whole field will be contracted so that only an 
insignificant patch remains. In some cases scotomata are found. Usually 
the color-field is lost commensurate to the loss in the form-field. 

Spontaneous pulsation in the retinal arteries, while highly suggestive 
of glaucoma, is not pathognomonic, since the retinal arterial pulse is seen 
also m insufficiency of the aortic valves, in exophthalmic goitre, in aneu¬ 
risms of the aorta and innominate arteries, and sometimes in neurasthenia 
and chlorosis. 

Diagnosis.— It is between this form of glaucoma, optic-nerve atrophy, 
and cataract that the diagnosis will present most difficulties for the practi¬ 
tioner. The following diagnostic table may be of value:_ 


Glaucoma Simplex. 

Tension increased (at 
times early in the dis¬ 
ease, constantly later). 

Episcleral veins are dilated 
and tortuous. 

Cornea may be hazy and 
anesthetic. 

Anterior chamber may be 
shallow. 

Iris is normal at first, 
atrophic later. 

Pupil is slightly dilated 
early; dilated and fixed 
later. 

Pupil gives greenish or 
“glaucous” appearance. 

Slight pain is sometimes 
present in early stage. 

Knee-jerks are unaffected. 

Arterial pulsation is pres¬ 
ent or easily produced. 

Whole disc is excavated. 

All blood-vessels bend 
sharply over the edge of 
the disc. They may be 
seen indistinctly at the 
bottom of the excava¬ 
tion, and can be brought 
to view by using a 
weaker convex or 
stronger concave glass 
in the ophthalmoscope. 

Color-fields are commen¬ 
surate to form-fields. 


Optic-Nerve Atrophy. 

Tension is normal. 

Normal. 

Normal. 

Normal. 

j Normal. 

Normal or dilated; Argyll 
llobertson pupil is often 
present. 

Pupil is black. 

No pain. 

Often lowered or lost. 

Arterial pulsation is rarely 
present. 

Whole disc is concave— 
saucer-shape. 

Blood-vessels pass from 
disc into the retina with¬ 
out making sharp bend 
or curve. They are 
smaller than normal. 


Disproportionate loss. 


Cataract. 

Tension is normal, except 
in traumatic or compli¬ 
cated cataract. 

Normal. 

Normal. 

Normal or slightly shal¬ 
lowed. 

Normal. 

Normal. 


Pupil is whitish or grayish. 

No pain. 

Unaffected. 

No pulsation. 

Disc is normal. 

If the opacity in the lens 
does not prohibit the 
use of the ophthalmo¬ 
scope, the vessels appear 
normal. They may look 
blurred in one meridian 
and clear in another, 
from astigmatism. 












574 


MODERN OPHTHALMOLOGY. 


Oftentimes years elapse before the disease ends in absolute glaucoma, 
or a case of glaucoma simplex may suddenly show acute inflammatory symp¬ 
toms and soon the little vision remaining is destroyed. Late in the history 
of glaucoma simplex anyone can make a diagnosis. The eye is hard, the 
anterior chamber is shallow or obliterated, the pupil is dilated and fixed, 
the cornea is anesthetic, the lens is cataractous, and the globe is marked by 
enlarged and tortuous vessels. Pain is now a prominent symptom. 

Treatment. —Any disease of the general system, and particularly any 
disease of the nose, from which the patient suffers, must receive proper 
treatment. Fatigue and worry should be avoided. The patient should 
obtain sufficient rest, and excesses of all kinds should be avoided. As re- 



Fig. 345.—Field of vision of left eye in a case of glaucoma simplex. 

(Author.) 

The black area shows the contraction discovered at the first examination ; the shaded area 
shows the further losrfound six months later. 


gards the local remedies,—such as pilocarpin, eserin, etc.,—which some 
ophthalmologists use month after month and t’ear after year in cases of 
glaucoma simplex, the author wishes to enter a protest against their use 
except as mere temporizing agents. Many cases of blindness result from 
this form of glaucoma, the patient and physician wasting valuable time in 
using miotics. The period during which operative treatment might have 
done good is allowed to pass. The author is firmly of the opinion that 
every case of glaucoma simplex possessing vision equal to the counting of 
fingers at one foot or more should be given the benefit of an operation. The 
earlier an iridectomy is performed, the greater will be the probability of a 
favorable result. It is only fair to say, however, that, in cases of glaucoma 









GLAUCOMA. 


575 

simplex aa ith marked contraction of the visual field, great reduction in visual 
acuity, palpable increase of tension, and deep excavation of the nerve-head, 
ma ny eminent ophthalmologists regard iridectomy as contra-indicated. In 
such advanced cases it often occurs that iridectomy does not check the glau¬ 
comatous process and the patient soon becomes blind. In cases in which 
a lsion is on some dajs normal and others foggy, xvith beginning limitation 
of the field, an iridectomy should lie made as soon as the diagnosis is certain. 
If the result of this is to relieve the symptoms, and vision does not become 
less, the patient is dismissed with the injunction to return at once on the 



Fig. 346.—Section of superior cervical ganglion in chronic irritative 

glaucoma. (Author.) 

(Original drawing by Dr. Carl Fisch.) 

1, Artery. 2, A ein. 3, Area of small round-cell infiltration. 4, Normal nerve-cell. 5, Con¬ 
nective tissue. 6, Atrophied nerve-cell. (Leitz: ocular 4, objective 6.) 

advent of the old symptoms. If the iridectomy does not check the progress 
of the disease, the author resorts to sclerotomies and later, if necessary, re¬ 
moves the superior cervical ganglion of the sympathetic nerve of the same 
side. Miotics can be used at any time, but it is Avrong to let glaucoma pro¬ 
gress without exhausting all the therapeutic resources at our command. 
The question may be asked: “If excision of the sympathetic is so A r aluable in 
glaucoma simplex, why make an iridectomy ?” The answer is this: The bene¬ 
fits to be obtained from an excision of the superior cervical ganglion are 
greater in an eye from which part of the iris has been excised. 









576 


MODERN OPHTHALMOLOGY. 


Miotics are not to be entirely discarded, but their use should be limited 
chiefly to tiding the patient over the short period during which he can make 
arrangements for operative treatment. If the patient refuses operative 
treatment, a miotic should be prescribed. The best of these agents is 
arecolin. It is used in a 1 / 2 - to 1-per-cent, strength solution. Eserin and 
pilocarpin are also valuable miotics. Gentle massage, by the hand or by the 
ophthalmo-oscillator, employed twice a day, is sometimes followed by im¬ 
provement of vision and deepening of the anterior chamber. 

It must not be expected that any treatment twill cure all cases of glau¬ 
coma. However, the plan of treatment here outlined will show much better 
results than will the interminable use of miotics. These agents are use¬ 
less unless they contract the iris and lower the tension. They are without 
practical value in an old case of glaucoma with an atrophic iris. Eserin, 
when used alone, often causes congestion of the ciliary processes, possibly 
leading to increase of tension. If used in conjunction with cocain, the 
result is miosis, and, in favorable cases, reduction of tension occurs without 
congestion of the ciliary processes. When employed, eserin “should be used 
in the minimum amount and with the minimum frequency which suffice to 
contract the iris and keep it contracted” (Bull). The salicylate and hydro- 
bromate of eserin are preferred to the sulphate or hydrochlorate (Bull). 
Pilocarpin is said to lower the tension in some cases of glaucoma in which 
eserin fails. As Lilienfeld has shown, it may contain an impurity known 
as jaborin, an isomer of pilocarpin, which acts as a mydriatic. Hence, pilo¬ 
carpin preparations should be subjected to physiologic tests before being 
sold. 

Chronic Irritative Glaucoma (Chronic Inflammatory Glaucoma).—This 

form of glaucoma is distinguished from the acute variety by the constant 
presence of characteristic symptoms, which, during periodic exacerbations, 
become more marked. It presents prodromal symptoms. After a time the 
glaucomatous crises appear at shorter and shorter intervals. The eye re¬ 
mains hard. The cornea is steamy and opaque. The anterior ciliary veins 
appear dilated upon the bluish-gray sclera. The iris ceases to react to 
light; the pupil becomes dilated ad maximum , and finally the iris is reduced 
to a narrow band covered in large part by the conjunctival limbus. In 
advanced cases the iris loses its normal markings, its stroma disappears, and 
the pigment epithelium becomes visible. The cornea is anesthetic. The 
anterior chamber is shallowed by the forward movement of the lens. Pain 
of greater or less severity is an almost constant symptom. At intervals 
the steaminess of the cornea disappears, permitting an ophthalmoscopic 
examination. This shows the retinal veins to be dilated and tortuous, the 
arteries narrowed and pulsating either spontaneously or on slight pressure, 
and the optic papilla excavated. There is progressive reduction in visual 
acuity and progressive contraction of the visual field. The disease finally 
ends in complete blindness. Pain, however, persists, and makes the patient 
clamor for relief. 


GLAUCOMA. 


577 


Treatment. This form of glaucoma calls for an iridectomy. If 
this fails to reduce the tension, the superior cervical ganglion of the sympa¬ 
thetic may be excised or cyclicotomy may be tried. 

Acute Inflammatory Glaucoma.—Although this disease may appear 
suddenly, it is the rule that certain premonitory signs are known to have 
been present. They are often overlooked or are disregarded by the patient, 
to such an extent that the examiner must ask many questions to obtain the 
true history of the case. A patient who is about to be subject to an out¬ 
break of glaucoma will probably have had days of misty or foggy vision. 
He may have seen a rainbow-like appearance around a light; and these 
symptoms,may have been more noticeable after loss of sleep or in the pres¬ 
ence of great fatigue or strong emotional excitement. He may have changed 
his glasses more often than is usual for presbyopic persons. These symp¬ 
toms appear from time to time. The intervals between them may shorten 
and the condition known as glaucoma simplex may develop; or inflamma- 
torv symptoms may arise, and the case is then one of acute glaucoma. The 
exciting cause of an outbreak may be great weakness induced by fatigue, 
hemorrhage, or shocking news. Whatever the cause, the patient experi¬ 
ences excruciating pain in and around the eye. The sight is diminished 
and may be entirely lost in twenty-four hours, in the fulminant form of the 
disease. The conjunctiva and lids are swollen, and the eye is intensely red 
around the corneoscleral junction. The anterior chamber is shallow, the 
cornea is anesthetic, and the eyeball shows tension of -f- 2 or 3. The patient 
has fever and is restless. Often vomiting is a prominent sign, and it may 
lead to the belief that the case is one of sick headache or stomach trouble. 
Pain, being so prominent a symptom, may cause the practitioner to think 
he is dealing with iritis—an unfortunate diagnosis, resulting in loss of the 
eye. 

Diagnosis. —The diagnosis of acute inflammatory glaucoma can be 
made with the fingers. The increase of tension should be evident to any 
physician capable of the intelligent use of the sense of touch. The examina¬ 
tion is to be conducted as described in the chapter on examination of the 
eye. If the media are clear, the ophthalmoscope may or may not show the 
characteristic excavation of the head of the optic nerve. In some cases the 
vision is lost so rapidly that blindness ensues before excavation appears. 
In some cases of acute inflammatory glaucoma the head of the optic nerve 
appears swollen. 

Treatment. —This form of glaucoma usually yields to a properly 
executed iridectomy. If iridectomy fails to relieve the tension, the surgeon 
may employ a posterior sclerotomy or a cyclicotomy. If the case still 
progresses unfavorably, sympatheticectomy may be done. 

Hemorrhagic Glaucoma.—Intra-ocular hemorrhages occur in glaucoma. 
They may appear late in the history of the case—glaucoma with hemor¬ 
rhages; or, as is sometimes observed, hemorrhages appear in an apparently 
normal eye, and later the tension rises (hemorrhagic glaucoma). It is 


37 


578 


MODERN OPHTHALMOLOGY. 


necessary to draw clearly a distinction between these conditions, not only 
for prognostic, bnt also for legal, reasons. An operation which might be 
undertaken in an old case of glaucoma with hemorrhages would be entirely 
valueless in hemorrhagic glaucoma. 

Hemorrhagic glaucoma may be defined as an ocular disease, with in¬ 
creased tension, following a previous hemorrhagic retinitis. As Stirling 
says, it “must be distinguished from hemorrhage into an already glau¬ 
comatous eye”—a valuable point to which Bisley first directed attention. It 
is fortunately a disease rarely met with, Bisley and Oliver having found it 
but 13 times among 60,000 ophthalmic cases. 

Symptoms. —The patient usually seeks relief on account of failing 
vision due to intra-ocular hemorrhage, which is a result, as a rule, of some 
gross change in the vascular system (endarteritis or thrombosis). The 
symptoms of a subacute or of an acute glaucoma follow the hemorrhages at 
an interval of weeks or months. The ophthalmoscopic signs, where the 
media are clear, consist of tortuosity of the retinal vessels, and the presence 
of numerous flame-shaped hemorrhages, which are particularly abundant 
in the macular region. The optic disc may be red and hazy, or it may 
show pronounced neuroretinitis. The retinal arteries are usually small 
and the veins are large. Later in its history the eye shows the nerve-head 
deeply cupped and filled with lymph and blood. 

Etiology.— As regards age, most cases occur between 50 and 70 years. 
Weinbaum saw a case 36 years old and the author met with one, a young 
man, aged 35 years. The disease usually affects one eye only, although 
cases have occurred in which both were involved. The most constant of 
the general changes found in cases of hemorrhagic glaucoma is a general 
arteriosclerosis, which may be a part of or separate from general senile 
changes. The disease may follow the ocular changes of albuminuria. 
Treacher Collins considers that there is an analogy between hemorrhagic 
and primary glaucoma—a view which is opposed by many ophthalmologists. 
Alt considers that hemorrhagic glaucoma is always caused by hemorrhages, 
and that hypermetropia is behind the trouble. Hoyes saw cases due to, or at 
least associated with, embolism of the central retinal artery. Bichey be¬ 
lieves that the disease depends on disease of the vessel-walls which are too 
weak to bear increased arterial tension. Bisley states that “it is but a 
local expression of the disease of the general vascular tree, and as such 
anticipates in blindness the fatal result which in many cases speedily fol¬ 
lows.” 

Pathology.— The pathologic changes of hemorrhagic glaucoma are 
located in the eyeball and in the cervical portion of the sympathetic nerve. 
The ocular changes comprise inflammatory and degenerative lesions in the 
chorioid, iris, and ciliary body. In some cases the chief lesions are in the 
retinal vessels. The changes consist of “sclerosis, hyalin changes in the 
vessel-walls, obstruction of the lumen by thrombi, distension of the vascular 
canals with blood, and ruptures. With these, the signs of more or less 


GLAUCOMA. 


579 


gross inflammatory reactions in the surrounding tissues are constantly 
found (Oliver). The cornea may show bullae. The lens often is cataract- 
ous and the vitreous humor is shrunken. There are hemorrhagic extravasa¬ 
tions into the retina, which is usually detached and cystic. In cases where 
the process has long continued the cornea becomes ulcerated and the place 
of the vitreous is taken by grumous and gelatinoid exudates. Such eyes 
end in atrophia bulbi or in panophthalmitis. 



(Original drawing by Dr. Carl Fisch.) 


1, Pigmented nerve-cell. 2, Transverse section of non-medullated nerve-fibres. S, Net¬ 
work of intracapsular nerve-fibres. 4, Nerve-cell process. 5, Unpigniented nerve-cell. 6, 
Non-medullated fibres. 7, Nuclei of perineurium. S, Vein. 9, Polynudeated leucocyte. 

10 , Zone of round-cell infiltration. U, Mast-cell. 12, Artery. 13, Medullated fibres from 
motor spinal nerve. (Leitz : ocular 4, objective 6.) 

In a case of hemorrhagic glaucoma observed by the author the patho¬ 
logic changes of the eye could not be studied except ophthalmoscopically 
because an enucleation was not made, the excision of the superior cervical 
ganglion of the sympathetic nerve having rendered an enucleation unneces¬ 
sary. Sections of the ganglion show marked pathologic changes, as can be 
seen by comparison of Figs. 339 and 347. 

Prognosis.— The prognosis of hemorrhagic glaucoma is unusually 
grave. The disease heretofore has been considered not only fatal to sight, 
but in the large majority of cases removal of the globe has been necessary. 









580 


MODERN OPHTHALMOLOGY. 


In 28 eyes whose history was collected by Schweigger, vision was lost in all, 
and 24 were finally enucleated. Iridectomy, opticociliary neurectomy, 
and sclerotomy have been followed in almost all cases by hemorrhage re¬ 
quiring immediate removal of the globe or by a return of violent pain neces¬ 
sitating the same procedure. Recently, however, Oliver has recorded a 
more favorable prognosis from iridectomy performed slowly under general 
anesthesia, the patient being placed on a bed with the head much higher than 
the feet, so as to diminish the chances of increased blood-pressure. This 
surgeon, as a result of careful attention to his cases of hemorrhagic glau¬ 
coma, was able to save for three of eight cases almost normal vision for 
eight, six, and four years, respectively. The fields of vision in these cases 
are fairly large. In two other eyes of this series the disease was held in 
check for several months, the patients having useful .vision, but ended in 
further hemorrhages due to trauma. Two cases of hemorrhage into the 
fellow-eye, previously operated on, were followed by a permanently success¬ 
ful iridectomy on the second eye, the first eye being enucleated. 

Although Oliver's cases show an unusually successful result from slowly 
performed iridectomy in hemorrhagic glaucoma, the author believes with 
Abadie that the operation of sympatheticectomy probably offers a better 
chance of improvement than any operation which can be made on the 
eyeball. 

Treatment. —General treatment is required in every case. The pa¬ 
tient’s surroundings should be cheerful and hygienic. He should obtain 
sufficient sleep. All causes of excitement are to be avoided, and alcoholic 
beverages are to be prohibited. The internal administration of salicylate of 
sodium is useful. Abadie advises the administration of quinin and ergot. 
Search should be made for gouty, rheumatic, or syphilitic manifestations, 
and, if found, proper treatment should be instituted. 

As regards operative treatment, the choice lies between iridectomy and 
sympatheticectomy. Such questionable procedures as paracentesis of the 
cornea, anterior or posterior sclerotomy, scleral trephining, and stretching 
the external nasal nerve are out of place. Electricity is not indicated in 
this disease. 

Glaucoma Absolutum.—This term is applied when the glaucomatous 
eye is completely blind. The eye is then of stony hardness. The pupil, 
widely dilated, is of a greenish or dirty-gray color. The anterior chamber 
is almost completely abolished. The cornea is clear, but insensitive; and 
the distended anterior ciliary veins form a prominent network about the 
globe. 

At a later period, such an eye undergoes glaucomatous degeneration. 
The cornea becomes opaque, the lens cataractous, the sclera ectatic, and 
after a long period the globe undergoes softening and atrophy. It may 
develop an ulcus serpens of the cornea, with sequent iridocyclitis or panoph¬ 
thalmitis. Ribbon-like opacity of the cornea is frequent in eyes undergoing 
glaucomatous degeneration. During much of the period of glaucomatous 


GLAUCOMA. 


581 


degeneration the patient has subjective luminous impressions, which delude 
him into the belief that his vision will some day be restored. 

Treatment.— If the glaucomatous eye is entirely blind, it will demand 
no treatment so long as it is quiet. Unfortunately, however, such eves 
usually become very painful and the patient clamors for relief. Medicines 
are valueless in this condition. Heretofore the operations for the relief of 
pain in absolute glaucoma have been iridectomy, neurectomy, and enuclea¬ 
tion. Of these, iridectomy may be tried. Often, however, after making an 
c - m a or an excision of the optic and ciliary nerves, the pain will re¬ 
turn. The disadvantage of enucleation is that it causes a great deformity. 
A posterior sclerotomy may relieve the tension and pain. Excision of the 
superior cervical ganglion of the sympathetic nerve will relieve the pain 
of absolute glaucoma for a long period, and often enables the patient to 
ictain the eyeball. In the stage of glaucomatous degeneration only enuclea¬ 
tion is valuable. 



Fig. 34S.—Acquired hydrophthalmos. (Author.) 

The specimen, which is from a girl aged 15 years, shows complete adhesion of the pupil¬ 
lary margin of the iris to the lens, which is shrunken and displaced. The cornea is much en¬ 
larged, and through the greater part of its extent the iris is adherent to it. The iris is also 
atrophic. This eye measures: vertical diameter, 22 millimetres; axial diameter, 30 milli¬ 
metres. 

Treatment of the Apparently Unaffected Eye in Glaucoma is a matter 
of importance. Careful examination will frequently show that the appar¬ 
ently normal eye presents premonitory signs of glaucoma, in the way of 
transient increase of tension, obscuration of sight, slight steaminess of the 
cornea, etc. In such cases, although vision may be for most of the time 
normal, the author advises an iridectomy, which is to be made as soon as 
the eye first operated has recovered. This advice is especially to be urged 
upon patients who live far from competent ophthalmic surgeons. 

Glaucoma after Cataract Operation is discussed in the chapter on dis¬ 
eases of the crystalline lens (page 458). 

Prevention of Primary Glaucoma.— If errors of refraction and accom¬ 
modation were properly treated early in life, it is highly probable that the 
percentage of glaucoma cases would be much reduced. If a patient already 
has glaucoma, he should be urged to lead a regular and quiet life. Causes of 





5S2 


MODERN OPHTHALMOLOGY. 


excitement should be avoided. Stimulants should not be used. Previous 
to making an iridectomy or any other operation upon one eye a miotic should 
be instilled into the'other eye, to prevent an attack of glaucoma. 

Hydrophthalmos (Buphthalmos; Infantile Glaucoma; Congenital 
Glaucoma).—This is a rare disease of childhood, which is characterized by 
increased intra-ocular tension and enlargement of the eyeball in all of its 
diameters. The increase of tension is due to blocking of the drainage appa¬ 
ratus. Some writers speak of this disease as always congenital, but this is a 
mistake. The author has seen two cases in which the disease was acquired. 
In one it followed gonorrheal ophthalmia, in the other an injury. The 
latter case was that of a girl of 15 years, who, at the age of five years, was 
struck with the tine of a table-fork, which pierced the cornea and was fol¬ 
lowed by iris-prolapse. A surgeon desired to enucleate the eye, but the par¬ 
ents would not consent. The patient was lost sight of and ten years later 
came with pronounced hydrophthalmos. A section of the enucleated eye 
is shown in Fig. 348. How came it that this case was transformed from 
one of iris-prolapse into hydrophthalmos? Shortly after the receipt of 
the injury the wound closed and the aqueous humor separated the iris from 
the corneal wound. An iritis followed and, being untreated, adhesions 
fastened the iris to the lens-capsule, thus completely separating the pos¬ 
terior from the anterior chamber; and gradual accumulation of aqueous 
humor raised the intra-ocular pressure, with the result that the eye became 
enlarged. This could occur only in a child, since in the adult the sclera 
is unyielding except it be softened by inflammation. 

For anatomic reasons, the disease tends toward the production of 
grave changes in all the* structures of the eye. In response to increased 
intra-ocular tension, the eyeball increases in every diameter. The cornea 
becomes enlarged to such an extent that the term keratoglobus can be ap¬ 
plied with propriety. The lens, which is often rudimentary, is arrested in 
its growth; and the eyeball from being hypermetropic, or possibly emme¬ 
tropic, in the acquired form of buphthalmos becomes greatly myopic. 
Vision is gradually reduced by excavation of the optic-nerve head or by 
chorioidal and retinal changes. The globe protrudes to such an extent as 
to cause a hideous deformity. The eye shows signs of irritation. It is 
subject to frequent attacks of conjunctivitis and keratitis. The cornea 
becomes thin, and often looks bluish from contact of the adherent iris. 
The line of demarcation between the cornea and sclera is lost. The ciliary 
region often presents nodules. The anterior chamber may be of great 
depth in the centre and be obliterated at the periphery. Often the iris is 
atrophic and presents numerous rents. Generally a view of the depths of 
the eye cannot be had, because of opacities in the lens or the presence of 
exudation in the pupillary area. 

Cases of buphthalmos sometimes go on to spontaneous cure. Thus the 
increased tension may expand the eye up to a certain point, at which the 
enlargement becomes stationary, and the tension may become normal. 


GLAUCOMA. 


583 


Although such an eye remains large and the sight is defective, no further 
increase occurs and vision is not further impaired. 

Etiology. —The causes of acquired hydrophthalmos are trauma and 
perforating corneal'ulcers. As regards the cause of the congenital form, 
there is much doubt. Johnson reports the occurrence of the disease in three 
children in the same family. A failure of the iris to separate from the 
posterior surface of the cornea at its extreme periphery can occur unasso¬ 
ciated with anterior synechia elsewhere, and this offers an easy explanation 
of congenital buphthalmos; but why this separation should not take place 
is not known. Collins has made microscopic examinations of several eyes 
afflicted with congenital glaucoma, and has found that in all the angle of 
the anterior chamber was closed by adhesion of the root of the iris to the 
cornea. The canal of Schlemm may be absent. 



Fig. 349.—Binocular hydrophthalmos following ophthalmia neonatorum. 

(Author.) 

Diagnosis. —Hydrophthalmos may be mistaken for interstitial kera¬ 
titis. These diseases present somewhat similar appearances in their initial 
stage. The differentiation can be made by the state of the tension, which is 
increased in hydrophthalmos. 

Prognosis and Treatment.— Iridectomy in this disease is rarely fol¬ 
lowed by improvement. During, the operation the zonula is likely to be¬ 
come ruptured and there is loss of vitreous humor. Bergmeister has 
recorded the case of a child, aged 13 years, on whom he made an iridectomy 
for congenital hydrophthalmos when the patient was six months old. A 
cure followed the operation. Stolting has had favorable results from 
repeated sclerotomies. Snellen treats these cases by paracentesis of the 
anterior chamber. Sympatheticectomy has been tried in a few cases with¬ 
out improvement. The use of miotics is of little, if any, value. When the 
eye is greatly enlarged, thus causing a deformity, and vision is lost, enuclea- 




584 


MODERN OPHTHALMOLOGY. 


tion or a Mules operation is to be advised. Such eyes are sources of both 
physical and mental suffering. 

SECONDARY GLAUCOMA. 

This term is applied to all cases in which increased intra-ocular tension 
comes from other pathologic processes. It may be acute or chronic. Among 
the chief causes of secondary glaucoma are: (1) a neglected iritis, leading to 
closure of the aqueduct from the posterior to the anterior chamber; (2) 
incarceration of the iris in a corneal or scleral scar; (3) ectasias of the 
cornea and sclera; (4) iridocyclitis, which, as a rule, leads to only tem¬ 
porary increase of tension; (5) closure of a corneal fistula; (6) rapid 
swelling of an injured lens; (7) dislocation of the lens; (8) hemorrhages 
into the retina; (9) the growth of intra-ocular tumors; (10) chorioiditis 
and high myopia. These conditions are all considered elsewhere in this 
treatise, and do not call for further consideration in this place. 


HYPOTONY. 

Hypotony is a diminution of intra-ocular tension, and indicates a 
reduction in volume of the contents of the eyeball. It follows perforating 
wounds or ulcers, and occurs in cases of atrophy of the globe after iridocy¬ 
clitis. It is found after injury to the cervical portion of the great sympa¬ 
thetic nerve or after removal of its ganglia. Slight reduction of tension 
follows the use of a bandage which has been tightly applied to the eye, 
and is a common symptom in cases of keratitis. The local use of cocain 
causes slight hypotony. Dionin is said to produce a similar effect. 


OPERATIONS FOR GLAUCOMA. 

Of the many operations which have been proposed for the cure of 
glaucoma only three or four are worthy of mention. They are iridectomy, 
sclerotomy, eyclicotomy, and excision of the superior cervical ganglion of 
the sympathetic nerve. Not one of these procedures can be depended upon 
to cure all cases of glaucoma. It will be. found advisable in some cases to 
employ two of these operations at different periods, or it may be necessary to 
make an iridectomy twice on the same eye, to control the tension. Of the 
operations mentioned, iridectomy, introduced by von Graefe in 1857, lias 
long held sway as the chief treatment for glaucoma. Sclerotomy and 
eyclicotomy have never attained the popularity which has been accorded to 
von Graefe’s operation. Becently, in 1897, Jonnesco performed an opera¬ 
tion for glaucoma which had been already suggested by Abadie, viz.: ex¬ 
cision of the superior cervical ganglion of the sympathetic nerve. The 
favorable results obtained by Continental surgeons—Jonnesco, Abadie, 
Beclus, Gerard-Marcliant, Chauffard and Quenu, Jennet and Bled—in the 
treatment of glaucoma by this procedure led the author to adopt the opera- 


GLAUCOMA. 


585 


tion early in its history. Unfortunately in many of the cases treated by 
this method the ultimate results have not been satisfactory. 

Iridectomy. An iridectomy for glaucoma is a much different operation 
I tom an excision of the iris for an optical purpose. The latter requires 
the removal of a small part of the iris through an incision made in the cor¬ 
neal tissues. The former contemplates the excision of two-fifths of the 
iris-tissue through an incision made in the sclera close to or through the 
canal of Schlemm. The amount of iris-tissue removed is of less importance 
than is the site of operation. The object is to restore the drainage of the 
anterior chamber. The instruments required are a speculum, fixation-for¬ 
ceps, bent keratome or the narrow von Graefe cataract-knife, iris-forceps, 
scissors, and spatula. While the iridectomy for an optical purpose can 
often be made under cocain or holocain anesthesia, the operation for glau¬ 
coma usually requires general anesthesia for its successful execution. When¬ 
ever possible the excision is to be made upward so that the upper lid may 
cover the coloboma. A more important rule is to excise that part of the 
iris which is least adherent to the cornea: i.e., the incision is made oppo¬ 
site the deepest part of the anterior chamber. The ordinary precautions 
for surgical cleanliness having been observed, the operator introduces the 
speculum, fixes the globe, and passes the keratome at a point one millimetre 
behind the limbus. The instrument is steadily pushed into the anterior 
chamber, making a wound five or six millimetres in extent. As the kera¬ 
tome is passing into the eye the handle must be depressed sufficiently to 
prevent injury to the iris and lens. This often is a difficult procedure, 
owing to the shallowness of the anterior chamber. In such cases— i.e., 
where the anterior chamber is very shallow—a scleral puncture should first 
be made with a von Graefe knife at a point five to seven millimetres behind 
the cornea. This procedure is followed by a sinking of the lens and a con¬ 
sequent deepening of the anterior chamber. The keratome must be with¬ 
drawn slowly in order that the reduction of intra-ocular pressure may not 
occur too rapidly and cause hemorrhage from the retinal vessels. The iris 
is drawn out of the eye and cut at one extremity of the scleral incision. 
Another cut is then made at the opposite end of the wound, and, last, the 
piece of iris to be removed is to be cut off as close to the base as possible. 
The angles of the iris-coloboma are to be freed by the spatula. It is of the 
greatest importance that the iris shall not become entangled in the wound. 
An ordinary gauze dressing and bandage are applied to both eyes. The 
dressing is changed the next day, at which time 1 drop of a 1-per-cent, 
strength solution of atropin is used for the purpose of preventing adhesion 
of the iris to the lens-capsule (Uoyes). This is the only place and time in 
a case of glaucoma in which dtropin should he used. The after-treatment 
of the case is usually uneventful. 

Iridectomy in the Aphakic Eye.—Here a blunt hook is used to draw 
the iris out into the wound, forceps frequently failing to grasp it. Com¬ 
monly a bead of vitreous will be lost, since in most cases of glaucoma which 


586 


MODERN OPHTHALMOLOGY. 


appear in the aphakic eye there is vitreous humor in the anterior chamber. 
The iris, drawn out by the hook, is held with forceps and excised. The 
spatula is used as mentioned before. Recovery is generally uninterrupted. 

Accidents. —Any one of several accidents may occur during an iri¬ 
dectomy for glaucoma: (1) the surgeon may pass tlie keratome too far 
forward, thus failing to open the canal of Schlemm, or (2) too far backward, 
injuring the ciliary body or lens; (3) failure to tilt the keratome for¬ 
ward after penetrating the cornea may cause the point of the instrument 
to injure the iris or lens-capsule; (4) sudden withdrawal of the instru¬ 
ment, by rapidly lowering intra-ocular pressure, may cause rupture of a 
retinal vessel; (5) prolapse of vitreous may occur; (6) the angles of the 
iris-coloboma may be entangled in the wound; or (7) ill-directed traction, 
the use of an imperfect instrument, or too great force used in withdrawing 
the iris may cause iridodialysis and free hemorrhage into the anterior cham¬ 
ber, thus obscuring a view of the angles of the iris-coloboma. A miotic 
should not be used immediately preceding an iridectomy, since under such 
circumstances considerable force is required to draw the iris out of the 
wound, and iridodialysis may be caused. 


A B 



Fig. 350.-—Appearance of pupil after iridectomy for glaucoma. 

A, The lips of the iris are straight. B, The one lip of the iris is incarcerated in the wound. 

Sympatheticectomy.—This is a major operation, demanding general 
anesthesia, scrupulous cleanliness, and an accurate knowledge of anatomy. 

The skin from the clavicle to the ear, and from the median line in front 
to the spine posteriorly, should be shaved, scrubbed, and a bichlorid pack 
should be applied several hours before the operation. The hair behind the 
ear should be removed from a surface half the size of the palm. Imme¬ 
diately before the operation the skin should be washed in a strong solution 
of potassium permanganate, which is followed by a solution of oxalic acid. 
A bichlorid solution is used as a wash immediately before the operation. 

The steps in the procedure are: (1) the incision and separation of tis¬ 
sues down to the vertebral column, (2) identification of the sympathetic 
nerve, (3) excision of the superior ganglion, and (4) closure of the wound 
and after-treatment. 

1. The Incision should be four or five inches in length and should be 
made always behind and parallel with the posterior border of the sterno- 
cleido-mastoid muscle. It should begin at a point over the occipital bone 


GLAUCOMA. 


587 


coi responding to the origin of the muscle. The incision generally involves 
the external jugular vein, which is tied in two places before being cut. 

After incising the skin and superficial fascia the deep fascia is reached 
and the spinal accessory nerve is cut, permitting* the operator to separate 
the sterno-cleido-mastoid muscle completely from the adjacent tissues. The 
deep dissection is done with the fingers or with a blunt instrument, never 
with a sharp one. The upper part of the wound can be enlarged by cutting 
with scissors until the skull is reached. It is important to do this if the 
surgeon expects to remove the greater part of the superior ganglion. The 
separation of tissues down to the vertebral column can be done rapidly with 



Fig. 351. Site of the incision for removal of the superior cervical 
ganglion of the sympathetic nerve. (Author.) 

the fingers, provided the operator follows the intermuscular fascia. The 
carotid sheath is pulled forward with the sterno-mastoid muscle by a re¬ 
tractor and the trapezius muscle is held backward in the same way, thus 
permitting an inspection of the deep wound. The landmarks to be followed 
are the transverse processes of the vertebree. 

2. The Identification of the Sympathetic Nerve is sometimes 
easy, at other times exceedingly difficult. The variations in the size and 
situation of the cervical portion of the sympathetic nerve cannot be appre¬ 
ciated by reading text-books on anatomy, but must be observed on the living 
subject. It is generally stated that the sympathetic nerve is inclosed in a 
sheath separate from and behind the carotid sheath. This often is not true. 



588 


MODERN OPHTHALMOLOGY. 


Several times the author has seen the sympathetic lying alongside the pneu- 
mogastric nerve, inclosed in the same fascia with the internal jugular vein 
and the carotid artery. On this account, and for the additional reason that 
the pneumogastric and sympathetic nerves often are of the same size, it 
is wise to open the carotid sheath extensively and follow the nerves down¬ 
ward to the point where the middle cervical ganglion is located. This, 



Fig. 352.—Operation for excision of the superior cervical ganglion 
of the sympathetic nerve. (Author.) 

(Original drawing by Dn. R. W. Mills.) 

At the upper part of the wound is the superior cervical ganglion ; at the lower extremity 
is the middle ganglion. Deep in the wound are the internal jugular vein, carotid artery, and 
pneumogastric nerve. 

of course, will settle the question of identification, since the pneumogastric 
nerve has not a middle ganglion. If the middle ganglion of the sympa¬ 
thetic nerve should be absent, the operator should follow each nerve upward 
to the farthest possible extent. The spindle-shaped superior ganglionic 
expansion of the sympathetic serves to identify the nerve to be excised. If 
this method of identification should fail, the surgeon can pick up each nerve 












GLAUCOMA. 


589 


separately and irritate it, and watch the effect on the heart. The one whose 
irritation affects the heart should not be excised. 

The surgeon cannot depend upon the size of these nerves, since the two 
have been seen lying together and of the same size and color. The pneumo- 
gastric may be so much atrophied that it is scarcely larger than a pin’s 
head, and the sympathetic may be large or small. 

3. Excision of the Ganglion.- — The nerve having been identified, 
the next step is to excise the ganglion. The operator first separates the 
ganglion to the base of the skull; the numerous branches given off from the 
ganglion are cut; the ganglion is held taut with forceps by an assistant, 
while the operator places the left index finger under it and cuts the ganglion 
as high as possible, using strong curved strabisnjus scissors. The excision 
is completed by severing the nerve-strand an inch below the ganglion. 

4. The Closure of the Wound is done with superficial sutures. It 
is not necessary to use deep sutures. The after-treatment in the author’s 
cases has been uneventful. The author’s first patient was put up in a 
plaster dressing, which was uncomfortable and unnecessary. 

When properly done there is only trifling hemorrhage from this opera¬ 
tion. The patient leaves the hospital on the sixth or seventh day. An un¬ 
pleasant sequel is severe pain located in the neck and shoulder. 

Effects of Excision of the Superior Cervical Ganglion. —The 
effects of removal of this ganglion are immediate and remote. The im¬ 
mediate effects are relief of ocular pain, the production of lacrimation and 
conjunctival injection, together with a discharge from the corresponding 
nostril, unilateral sweating, and contraction of the pupil. Often there is an 
immediate reduction in intra-ocular tension. The pupillary and conjuncti¬ 
val changes are noted within five minutes after the excision. 

The remote effects are ptosis, which appears on the third or fourth day, 
improvement of vision, and in some instances a tardy contraction of the 
pupil and a tardy reduction of intra-ocular tension. To these there must 
also be added a slight sinking of the eyeball into the orbit (enophthalmos), 
and a feeling of heaviness in the head. 

Immediate reduction of intra-ocular tension does not always occur. In 
the author’s second case at the end of eight days the tension was -j- 2. On 
the sixteenth day it was normal. In the first case reduction of the tension 
was immediate. The relief from pain in the first case was immediate and 
lasting. This patient had not been free from pain for two months pre¬ 
viously. The slight ptosis following sympatheticectomy is to be attributed 
to paralysis of Muller’s muscle. Sinking of the eyeball is no doubt due to 
paralysis of the unstriped peribulbar muscular fibres which are found in 
Tenon’s capsule. 

Contraction of the pupil is usually an immediate result; it may, 
however, appear tardily. Thus, in the author’s first case the pupil was 
unchanged until the fourth day after the operation; and it did not be¬ 
come at any time as markedly contracted as in the other patients. In the 


590 


MODERN OPHTHALMOLOGY. 


third case—that of optic-nerve atrophy—the pupil was markedly contracted 
within five minutes after the excision. 

Lacrimation, conjunctival injection, and nasal moisture are transient 
symptoms which are generally absent after the first or second day. 

The immediate improvement in vision following excision of the superior 
cervical ganglion is remarkable; but unfortunately in many cases it is not 
lasting. It must be stated, however, that the cases in which sympatheticec- 
tomy has been performed have been usually desperate ones—cases in which 
no good result would be expected from iridectomy. It is highly probable 
that this operation will give more satisfactory results if performed earlier 
in the history of the case. 

Conclusions as to the Value of Sympatheticectomy.—1. Ex¬ 
cision of the superior cervical ganglion is a valuable procedure in glaucoma, 
but is not to be ranked with iridectomy in remedial value. While, in gen¬ 
eral terms, excision is not to be advised in non-iridectomized eyes, such 
excision is admissible under the following circumstances: (1) where iridec¬ 
tomy or sclerotomy is refused, (2) in hemorrhagic glaucoma, and (3) in 
glaucoma simplex with great loss of vision. 

2. Sympatheticectomy is of more value in glaucoma simplex than in 
inflammatory glaucoma. 

3. In inflammatory glaucoma, on which iridectomy has been done with¬ 
out benefit, excision of the superior cervical ganglion may be tried. 

4. In cases of absolute glaucoma with pain sympatheticectomy may be 
tried before resorting to enucleation. 

5. In unilateral glaucoma excision of the sympathetic ganglion is to be 
done only on the corresponding side. 

6. In the hands of a careful operator excision of the superior and mid¬ 
dle ganglia is a safe operation. Of nearly 100 cases of glaucoma in which 
this operation has been performed, 1 death has been reported, which was 
due to accidental infection. 

7. The post-mastoid route is to be preferred in excision of any part 
or all of the cervical sympathetic. 

8. Whether the curative effects of sympatheticectomy are as lasting as 
those of iridectomy and cyclicotomy (Hancock’s operation) is question¬ 
able. 

9. It is not yet known whether or not sympatheticectomy can pre¬ 
vent glaucoma. 

Large Paracentesis of the Sclerotic with Cyclicotomy (Sclerocyclo- 
cotomy; Hancock's Operation).—This operation was performed by Hancock 
on the supposition that glaucoma is caused by spasm of the ciliary muscle 
causing a stasis in the intra-ocular circulation. The procedure is as follows: 
The eye having been anesthetized by cocain, the lids are held apart by the 
thumb and fingers, which are also used to steady the eye. The surgeon 
passes a Beer cataract-knife, with its cutting edge downward, into the sclera 
at the lower margin of the cornea, the incision being made between the 


GLAUCOMA. 


591 


external and inferior rectus muscles. The instrument is quickly passed 
downward and backward into the vitreous until one-third to one-half of the 
blade is hidden. In withdrawing the instrument it is slightly turned so that 
the wound gapes, permitting the aqueous humor and a small amount of 
the vitreous to escape. Poliak, who practiced this procedure for forty 
years, says: “A few seconds only are required for this operation. No dress¬ 
ing or an} 7 after-treatment is needed. The relief from increased tension and 
pain is instantaneous. The lens recedes to its normal position, the pressure 
upon the ciliary processes is removed, the iris being freed from pressure soon 
resumes its normal place, the spaces of Fontana are gradually opened, and 
so also is the canal of Schlemm.” Those who have performed this operation 
are so well pleased with the results that it should be more generally em¬ 
ployed. It will be advisable, however, to bandage the eye for two or three 
days after the operation. 

The author has tried Hancock’s operation twice only, with satisfactory 
results. The first patient had had a broad iridectomy made several years 
before for glaucoma. The eve took on an attack of acute inflammatory 
glaucoma; tension was much increased, and vision was reduced to perception 
of light. There was intense pain. Within ten minutes after performing 
Hancock’s operation the eye was free from pain and within a week there 
was restoration of vision to 2 % 0 - The other patient was an old and feeble 
woman, with absolute glaucoma, to whom the administration of a general 
anesthetic would have been dangerous. Hancock’s operation was followed 
by immediate relief of pain and reduction of tension. Six months later the 
eye was quiet and the tension was normal. 

Sclerotomy.—Sclerotomy was introduced by Quaglino for the reason 
that leading ophthalmologists believed that the beneficial effects of iridec¬ 
tomy in glaucoma were due, not to excision of the iris, but to the cutting 
of the sclera. Sclerotomy may be anterior or posterior to the attachment 
of the iris. Some few surgeons prefer anterior sclerotomy to all other 
operations for glaucoma; others employ it only in case of failure of iridec¬ 
tomy to reduce intra-ocular tension; and others again reserve it for hemor¬ 
rhagic glaucoma or for the glaucoma following cataract extraction. In 
general it may be said that sclerotomy has gone out of vogue in the last ten 
years, and few surgeons now depend on it. Before a sclerotomy is made a 
miotic is used, and likewise it is employed for several days after the opera¬ 
tion. 

Anterior Sclerotomy. —The instruments required are a speculum, 
fixation forceps, a von Graefe knife or a keratome, and a spatula. Iris- 
forceps and scissors, or de Wecker’s pince-ciseaux , should be at hand as 
reserve instruments. There are several methods of performing this opera¬ 
tion. Before attempting any one of them a miotic should be used. 

1. Quaglino’s Method .—A keratome is inserted two millimetres behind 
the corneoscleral junction, passing as close to the iris as possible, making 
a wound three to five millimetres in extent. The instrument is withdrawn 


592 


MODERN OPHTHALMOLOGY. 


slowly so as to avoid prolapse of the iris. Snellen employs this procedure. 
This operation has not met with the favor which has been accorded to 

2. De Wecker’s Method .—A narrow von Graefe knife, or a specially 
made instrument called a sclerotome, is passed transversely across the eye at 
a point one millimetre behind the corneoscleral junction. The puncture 
and counterpuncture are enlarged by sawing movements. The knife is 
slowly removed before the section is complete, thus leaving a bridge of 
sclerotic between two wounds. 

Comparative Value of these Methods .—Sclerotomy with the von Graefe 
knife is the more difficult of proper execution. It is less easy to control 
the proper anatomic position of the wound; prolapse of iris is more likely 
to occur, particularly near the point of counterpuncture; and more definite 



Fig. 853.—Posterior sclerotomy. (After Czermak.) 

scarring of the eye results with the possibility of unpleasant sequelae. 
Sclerotomy with a keratome can give a satisfactory result without any trace 
of the operation remaining. 

Accidents .—The iris may be punctured by the knife or keratome. If 
the lens is uninjured the accident is of no importance. If, after the incision 
has been made, the pupil is drawn toward the wound, it indicates that the 
peripheral part of the iris has become incarcerated in the lips of the wound. 
The iris should be released with a metal spatula. If this cannot be accom¬ 
plished, it will be advisable to make an iridectomy. If prolapse of iris 
occurs during the operation an immediate iridectomy will be in order. The 
healing process not infrequently is not smooth, the formation of an elevated 
and nodular scar being not uncommon. These scars lead to fistulas, and 
may be the cause of prolonged irritation which yields only to an iridectomy. 



GTLAUCOMA. 


593 


Some authors regard a bulging scar as a safeguard, the aqueous humor fil¬ 
tering through it and passing under the conjunctiva, thus reducing the intra¬ 
ocular tension. Such a condition must be regarded as dangerous. 

Posterior Sclerotomy, incision of the sclera behind the attachment 
of the ins, is employed for the following conditions: (1) removal of foreign 
bodies in the vitreous chamber; (2) the removal of intra-ocular parasites 
(cysticercus) ; (3) in detachment of the retina; (4) in glaucoma either 
as a primary operation or in cases in which iridectomy has failed; (5) 
as a step preliminary to iridectomy in cases where the anterior chamber 
is much shallowed; (G) in traumatic hemophtlialmos without rupture of 
the cornea or sclera. 

The operation may be simply a puncture for the relief of increased 
tension, for the cure of detachment of the retina, or to hasten the absorption 
of blood in traumatic hemophtlialmos; or it may be an incision of con¬ 
siderable size, as in the operation of removal of a foreign body or parasite 
m the vitreous chamber; or it may be an incision for the purpose of dividing 
the ciliary muscle, as in Hancock’s operation for glaucoma. A simple punc¬ 
ture or an incision is made with the von Graefe cataract-knife, while Han¬ 
cock’s operation (selerocyclocotomy, cyclicotomy) is usually made with the 
knife of Beei. Accessory instruments are a speculum and fixation-forceps. 
Precautions having been taken to insure asepsis, under holocain anesthesia 
the knife is passed through the sclera. Its direction will depend on the pur¬ 
pose of the operation, but usually it will be meridional. Some operators 
give the wound a curved, an L-, or a T-shape. Generally the incision is 
placed in the lower external quadrant, between the attachments of the in¬ 
ferior and external recti muscles, and is five or six millimetres long and one 
centimetre deep. In puncture for detached retina the knife must often be 
cai i icd to a gieatei depth. The eye is to be bandaged for a few days and 
healing is usually without incident. 


88 


CHAPTER XVIII. 

SYMPATHETIC EYE DISEASES—INDICATIONS FOR 

ENUCLEATION. 

By the term sympathetic eye diseases we understand those pathologic 
conditions which are produced in the second eye by the internal transmission 
of an affection previously existing in the first eye. The eye which becomes 
diseased by reason of a disease of or an injury to its fellow is called the 
sympathizer, while the other is known as the exciter. For many years 
sympathetic eye diseases have been divided into sympathetic irritation and 
sympathetic inflammation. Begardless of the attempts to efface the differ¬ 
ence between these conditions and affirm the existence of a transition state, 
we must adhere to the essential clinical differences of both affections. 

Sympathetic Irritation is an abnormally strong irritability, often 
united with diminished functional power, which appears in all the centrif¬ 
ugal and centripetal ocular nerves, depending on irritation of the cen¬ 
tripetal nerves in the eye primarily diseased. The sympathetic disease ends 
with the disappearance of this irritation. 

Sympathetic Inflammation, or sympathetic ophthalmia, the ophthalmia 
migratoria of Deutschmann, is a progressive ocular disease attended with 
hyperemia and exudation, produced by a disease previously existing in the 
other eye, and not materially influenced in its course by the cure or removal 
of the exciting eye. 

In sympathetic diseases it is probable that the entire nervous apparatus 
of the exciter is concerned in the transmission of disease to the sympathizer. 
The condition producing sympathetic diseases is uveitis (iridocyclitis, irido- 
chorioiditis), which is generally caused by one or other of the following 
conditions: (1) wound of the ciliary region; (2) lodgment of a foreign 
body in the eye; (3) perforating wound or ulcer with incarceration of the 
iris in the corneal cicatrix; (4) operations upon the eyeball—a rare cause 
of sympathetic ophthalmitis; (5) dislocation, wounds, or calcification of the 
lens; (6) intra-ocular tumors when causing iridocyclitis; (7) intra-ocular 
cysticercus (the cause in a few cases) ; (8) ossification of the chorioid and 
ciliary body; (9) various rare causes, such as tattooing of the cornea, 
herpes zoster ophthalmicus, symblepharon, and the wearing of an artificial 
eye; (10) incarceration of the stump of the optic nerve in the cicatrix 
following enucleation; (11) blows on the eye without external wound 
(Mackenzie, Knapp, Schirmer, and Bronner) ; (12) blows, with subcon¬ 
junctival rupture of the sclera; (13) in one case a burn by lime was fol¬ 
lowed by sympathetic ophthalmitis (Koyes). 

In case the exciting eye has not been removed, its condition is gen¬ 
erally that of beginning or complete phthisis bulbi. In the study of sym- 
(594) 


SYMPATHETIC EYE DISEASES—ENUCLEATION. 


595 


pathetic eye diseases an important question is this: Are sympathetic irri¬ 
tation and sympathetic inflammation different stages or degrees of the same 
process, or are they two entirely different processes? Although many 
authors believe that irritation is an early stage of sympathetic inflammation, 
lcie are so many well-authenticated cases where sympathetic inflammation 
suddenly appeared without signs of irritation that we must hold strictly 
to the non-identity of these affections. Hence the great importance of 
enucleating the injured eye without waiting for the advent of sympathetic 
irritation in its fellow. 

SYMPATHETIC IRRITATION. 

Sympathetic irritation (sympathetic neurosis) is a functional disease 
presenting a great variety of symptoms referable to the ocular nerves and 
manifested by increased excitability and diminished functional power. 
W hctlier the affection is more frequent in neurasthenics than in persons with 
normal nervous systems is a mooted point. The frequency of sympathetic 
irritation cannot be determined accurately, since its manifestations are often 
overlooked by both surgeon and patient in their anxiety for the injured 
member, rain in and around the eye, radiating through the ciliary branches 
of the trigeminus, is a common symptom, the periorbital and frontal 
branches being often involved. It is rarely the case that the pain involves 
the whole trigeminal distribution. In some cases there is a feeling that the 
head is incased in an unyielding band. In other cases the pain is described 
as sticking or boring. These ciliary neuralgias must not be confounded 
with pain radiating from the injured eye. The pain of sympathetic irrita¬ 
tion, like the other symptoms, promptly subsides on removal of the exciting 
e\ e. Other prominent symptoms are photophobia, blepharospasm, dimin¬ 
ished accommodative power, contraction of the visual field, muse*, photop- 
sia, diminished visual acuity, pericorneal injection, hyperemia of the fundus, 
and tenderness over the ciliary region. Spasm of the ciliary muscle and 
spastic miosis are rare symptoms. The eye tires easily and waters when 
used for near work or on exposure to light. While a slight redness or haze 
of the optic papilla may be present, careful examination fails to show any 
signs of intra-ocular inflammation. 

Etiology. Sympathetic irritation can be produced by various causes, 
such as insignificant injuries; loss of corneal epithelium; the lodgment of 
foreign bodies in the cornea or under the upper lid; staphyloma of the 
cornea and sclera; iridocyclitis; luxation of the lens, especially if it is cal¬ 
cified ; rapid swelling of the lens after discission or trauma; or the lodgment 
of foreign bodies within the eyeball. In all these cases a slight degree of 
sympathetic irritation may be readily overlooked. Patients with svmpa- 
thetic irritation often present a shrunken globe, which may be due to ex¬ 
ternal causes (traumata), to a perforating ulcer, or to a spontaneous ocular 
inflammation. The interval between the involvement of the first eye and 
the advent of sympathetic irritation in its fellow varies from a few seconds 


596 


MODERN OPHTHALMOLOGY. 


to a period measured by the life of the individual. In the former case a 
foreign body lodging in the cornea is followed immediately by sympathetic 
irritation, while in the latter instance a period of quiescence lasting thirty 
or forty or more years is ended by the occurrence of pain, photophobia, and 
pericorneal injection in the good eye. In such cases anatomic examination 
of the enucleated globe will often show ossific deposits in the shape of a shell, 
corresponding to the chorioid coat, or the presence of minute spieulse of 
irregular form. Not rarely do we find sympathetic irritation after enuclea¬ 
tion of the injured eye, or following the placing of a glass or metallic globe 
in Tenon’s capsule, or in the sclera according to Mules’s operation. Sympa¬ 
thetic irritation may even occur after enucleation, where the stump of the 
optic nerve is involved in adhesions and the conjunctiva is not markedly 
retracted. It also occurs as the result of wearing an improperly fitting arti¬ 
ficial eye. In all these cases the cause of sympathetic irritation rests in 
irritability of the ciliary nerves. 

Diagnosis.—The diagnosis must concern (1) the existence of a sympa¬ 
thetic disease and (2) the differentiation between sympathetic irritation and 
sympathetic ophthalmitis. As regards the first contention, while sympa¬ 
thetic disease has no pathognomonic symptoms, disturbance of vision, the 
presence of pain in and around the eye, and the occurrence of pericorneal 
injection, photophobia, and blepharospasm or iridocyclitis appearing in the 
second eye as early as three or four weeks, or within four months after an 
injury to its fellow, will point to sympathetic disease. Occurring after the 
fourth month, such symptoms leave the diagnosis somewhat uncertain. 
However, in case of doubt it will be best to consider the case one of sympa¬ 
thetic disease until disproved. Schirmer states that the diagnosis of sympa¬ 
thetic inflammation cannot be made with absolute certainty, since identical 
symptoms may be due to other causes. The differentiation between sympa¬ 
thetic irritation and sympathetic ophthalmitis, which is of the greatest 
importance in prognosis, will perhaps be simplified by attention to the fol¬ 
lowing table:— 


Sympathetic Irritation. 

May appear in a few minutes or many 
years after injury. 

Pain, photophobia, pliotopsia, blepharo¬ 
spasm, lacrimation, hyperemia of the 
conjunctiva, obscuration of vision, 
weakness of accommodation, and ab¬ 
normal pupillary action are present. 

Objective signs are absent except in some 
cases the optic-nerve head appears 
hazy. 


Sympathetic Inflammation. 

Minimum interval known is two weeks; 
usually appears within three months 
after injury, but may be delayed for 
years. 

Sympathetic inflammation may be pre¬ 
ceded by these irritation symptoms, 
but often they are absent. 

Objective signs are those of definite in¬ 
flammation: plastic or serous iritis, 
keratitis punctata, and pericorneal in¬ 
jection. Papillitis may be absent, or 
present as a neuroretinitis or with 
retinal hemorrhages or edema. 



SYMPATHETIC EYE DISEASES—ENUCLEATION. 


597 


^ liile tlie diagnosis is usually not difficult, it must be remembered that 
cases are on record in which the conditions overlapped. Impaired vision in 
the sound e)e after an injury to its fellow may indicate simply sympathetic 
irritation; but the fundus should be examined for slight neuritis, which, 
if present, will indicate the onset of sympathetic inflammation. Such a 
case occurring in the author’s practice was cured by removal of the exciter 
and a long course of atropin and mercurials. 

Prognosis. Almost invariably proper treatment is followed by cessation 
of all irritation symptoms in this disease. In cases where the patient will 
not submit to operative intervention attacks of sympathetic irritation may 
recur at intervals for years without further damage; or, on the other hand, 
the eye may develop sympathetic ophthalmitis and be lost. It is impossible 
to foietell with certainty what kind of damaged eye will cause sympathetic 
disease or what will be exempt. Nor can the surgeon say what interval will 
elapse between the receipt of an injury and the development of sympathetic 
irritation. It is. because of this uncertainty that all cases, in which sympa¬ 
thetic irritation or inflammation may be- expected to develop, should be 

referred by the general practitioner to a competent ophthalmic surgeon 
without delay. 

Treatment.—In sympathetic irritation the first indication is to remove 
the source of trouble; and this presupposes an exact diagnosis of the condi¬ 
tion of both the exciter and the sympathizer. Removal of foreign bodies— 
wffiether in the cornea, conjunctiva, or elsewhere—will be in order. A 
luxated lens comes in this category. Mooren relieved a sympathetic irrita¬ 
tion of tw’o years’ duration by removal of such a lens. If the cause of 
imitation is a corneal staphyloma, it must be removed. If the ectasia is 
partial, or if posterior synechias are present, an iridectomy will suffice. If 
sympathetic imitation develops in a patient whose other eye has been re¬ 
moved, it will be necessary to submit the stump to the most careful scrutiny 
without local anesthesia. If exuberant granulations, swelling, and secre¬ 
tion are present, the inflamed patch should be excised or else should be 
touched with the solid stick of nitrate of silver. If the glass eye used by 
the patient is defective, it must be removed and a suitable one provided in 
its stead. If the conjunctiva is drawm backward, and is adherent to the 
stump of the optic nerve, a further resection of the nerve down to the 
optic foramen will be necessary. 

By far the largest and most important group of cases is that in which 
a blind or phthisical eye has caused sympathetic irritation. Such a globe 
will be tender on pressure, and should be removed either by enucleation 
or evisceration or else evisceration combined with the insertion of an arti¬ 
ficial vitreous (Mules’s operation). The value of these procedures will be 
discussed later on in this chapter. Such operations as section of the ciliary 
nerves and opticociliary neurotomy seem to the author to be inadequate in 
this condition. 


598 


MODERN OPHTHALMOLOGY. 


SYMPATHETIC OPHTHALMITIS. 

This disease begins insidiously, either with or without signs of sympa¬ 
thetic irritation. It pursues a persistent and destructive course. Once 
inaugurated, it rarely is checked by treatment. It is one of the most for¬ 
midable and obscure of ocular affections. While no age is exempt, the 
disease is much more liable to occur in children before or about the period 
of puberty. Any one of the conditions mentioned above as likely to cause 
sympathetic irritation may produce sympathetic ophthalmitis. The most 
frequent cause of sympathetic inflammation is perforating wounds, which 
do not heal readily, but undergo chronic inflammation. Only uveal inflam¬ 
mation caused by bacterial infection is capable of producing sympathetic in¬ 
flammation (Schirmer). Splinters which'have entered the eye aseptically 
never cause sympathetic inflammation (Schirmer). There is no relation¬ 
ship between the severity of the pathologic process in the exciter and the 
disease in the sympathizer. Often a slight cyclitis in one eye will be fol¬ 
lowed by complete disorganization in the other. Not infrequently does it 
occur that the exciter possesses useful vision both during and after the 
attack of sympathetic ophthalmitis. The disease commonly appears within 
two or three months after the injury to the fellow-eye, but it may commence 
in two or three weeks. On the other hand, of 211 cases recorded by the 
committee of the Ophthalmological Society of the United Kingdom, 12 
eyes became inflamed as late as twenty years after injury, and in 3 cases the 
interval was thirty-seven, thirty-eight, and thirty-nine years, respectively. 
It has been asserted that sympathetic ophthalmitis has been known to occur 
as early as the seventh day, and in Alt’s table of 110 eyes in 3 it appeared 
within eight days, but Schirmer states that the minimum interval in cases 
carefully observed is fourteen days. 

Fortunately sympathetic ophthalmitis is a rare disease. Thus, of 108- 
416 patients seen in private and clinical practice by Mooren, there were 
146 cases of sympathetic inflammation, or 1 to 742 (0.134 per cent.). 
0. Becker, among clinic patients, found 0.15 per cent, of sympathetic oph¬ 
thalmitis. Accurate statistics as to the frequency with which sympathetic 
ophthalmitis follows perforating wounds are wanting. That the disease 
is more frequent in men than in women is to be expected, since men are 
more exposed to injury. It is asserted that it is more frequent in summer 
than in winter, owing to the greater intensity of light and the greater viru¬ 
lence of bacteria in the warm season. 

Symptoms.—The clinical features of sympathetic ophthalmitis are by 
no means confined to this disease, since similar changes follow on general dis¬ 
eases and even occur apparently spontaneously (Schirmer). Hence the 
diagnosis can be made only by taking into consideration the history of the 
case, the interval between the injury and the involvement of the second eye, 
and the result of treatment. The process is an inflammation of the uveal 
tract, and may present either the serous or the plastic form. Where the 


SYMPATHETIC EYE DISEASES—ENUCLEATION. 


599 


. pathologic process begins is as yet undetermined; but, clinically, the altera¬ 
tions are found first in the iris. Earely does the disease manifest itself by 
changes in the optic nerve. 

1. Iritis (Uveitis Serosa).— The mild cases, known as iritis, or 
uveitis serosa, show slight pericorneal injection, and slight discoloration of 
the iris. The iris is adherent to the lens-capsule, the pupil is small, and the 
vision is reduced. These symptoms come on insidiously: i.e ., without pain. 
Dots appear on the posterior surface of the cornea. The anterior chamber is 
increased in depth, the media are cloudy, and the optic nerve, while gener¬ 
ally hazy and red, may show papillitis. The tension is at first slightly 
increased, then becomes variable, and in the later stages is permanently 
reduced. Frbm hyperemia the blue iris appears greenish and the dark one 
looks brownish. As was noted by Pagenstecher many years ago, sympathetic 
iritis permits enlargement of the pupil by atropin in spite of adhesions. 
Eecession of the iris-periphery is often seen. After a period lasting from a 
few weeks to several months, the e}’e, as a rule, recovers completely under 
proper treatment. The prognosis is favorable. Schirmer states that it is 
always favorable in the pure serous type of sympathetic uveitis, and he can 
conceive of the loss of such an eye only through increased intra-ocular ten¬ 
sion. The fact must not be overlooked, however, that the case may appear 
to be of the pure serous type, when, in reality, it is the beginning of the 
plastic variety. Such cases give an unfavorable result. 

2. Sympathetic Fibrinous Uveitis is the commonest as well as the 
gravest form of sympathetic ophthalmitis. As a rule, the first noticeable 
symptom is a slight ciliary injection. This may or may not be preceded 
by diminished accommodative power. Careful examination under a mag¬ 
nifying glass will show the presence of dots in the layer of Descemet, but 
these are often overlooked, and generally the patient does not consult the 
surgeon until vision becomes reduced. The eye will then show slight peri¬ 
corneal injection, muddiness of the aqueous humor, discoloration of the 
iris, the pupil being slightly contracted and readily enlarging on the use 
of atropin—a sign that the inflammation is not very acute. The changes 
in Descemet’s layer generally precede the formation of posterior synechige. 
The tension is usually slightly increased, but may be normal. Pain is a 
noteworthy symptom only in the rare cases running an acute course, and 
such cases may show swelling of the lids and conjunctival chemosis. Oph¬ 
thalmoscopic examination not rarely shows inflammatory changes in the 
papilla, as well as marked vitreous opacities. The frequency of the ophthal¬ 
moscopic changes has not been accurately determined, but Schirmer esti¬ 
mates that they exist in the earliest stages of sympathetic ophthalmitis in 
one-half of the cases. This form of papilloretinitis resembles the chorioido- 
retinitis of the secondary stage of syphilis. The papilla is abnormally red 
or grayish red, with blurred edges and without noteworthy swelling. A 
delicate grayish opacity passes from the disc into the retina. The veins 
are dark and somewhat tortuous; the arteries are normal. In many in- 


600 


MODERN OPHTHALMOLOGY. 


stances retinal changes are concealed by diffuse or dust-like opacities in the 
vitreous. Retinal hemorrhages are rarely associated with these changes. 
Chorioidal changes have been described by von Graefe, Haab, Hirschberg, 
and others. 

Keratitis punctata and turbidity of the aqueous humor are soon fol¬ 
lowed by posterior synechise. They spring from the pupillary margin of 
the iris and can be torn loose by strong mydriatics, but they also arise from 
the periphery, when the pupil is widely dilated. If the synechia is circu¬ 
lar, the iris is bulged forward by the hindered flow of aqueous humor, and 
intra-ocular tension is increased. This occurs only in a few severe cases. 
The formation of flat adhesions between the iris and lens-capsule is charac¬ 
teristic of typical malignant uveitis, and cannot be prevented by any 
mydriatic. This fibrinous exudation fills the entire posterior chamber and 
the space between the ciliary body and the lens. Hence, the iris is pushed 
forward, and the anterior chamber is shallowed. Soon the masses of exuda¬ 
tion shrink, followed by the ominous retraction of the iris, particularly at its 
periphery, thus showing that the surgeon has to deal with the severest form 
of sympathetic ophthalmitis. Meanwhile the iris looks macerated, and, 
owing to the marked swelling, it is disposed in radial folds, which remain 
because of uneven contraction of the retro-iridal deposit. Large, tortuous 
vessels are visible, and are due, not to arterial hyperemia, but to swelling 
from compression of their trunks in the ciliary body. The pupillary area 
becomes filled with a fibrinous exudate, which gradually increases in thick¬ 
ness and is the cause of the loss of vision. In the early stages the iris is soft 
and is easily torn, but later it becomes rigid and somewhat elastic. Where 
the corneal deposits are numerous, they become agglutinated, and, falling 
to the bottom of the anterior chamber, simulate hypopyon, which disappears 
later in the course of the disease. This condition was named purulent 
uveitis by Deutschmann, but Schirmer holds this to be only a severe form 
of fibrinous uveitis. 

In the further course of the disease the cornea loses its transparency, 
partly because of the increase of intra-ocular tension, partly by reason of 
cyclitis. Its deepest layers show fine, gray opacities, either diffused over 
the whole membrane or limited to its central part. The lens, also, becomes 
intransparent from the development of new vessels. Sympathetic fibrinous 
uveitis is eminently chronic in its course, lasting for months or years be¬ 
fore the turning-point is reached. In the few cases in which the globe is 
not destroyed a cure may take place, but recurrences of inflammation are so 
frequent that the eye must have been free of inflammation for a year before 
the surgeon can regard it as saved. Some of these cases will have useful 
vision by the clearing up of the opaque media. In others vision can be 
restored only by the performance of iridectomy, by the extraction of the 
opaque lens, or, in some few selected cases, by the drilling operation of 
Tyrrell. These operations are not to be lightly undertaken, and are prac¬ 
ticable only when a long period of quiescence has existed. If an iridectomy 


SYMPATHETIC EYE DISEASES—ENUCLEATION. 


601 


is made previous to this stage, the coloboma soon fills with fresh exuda¬ 
tion, and the visual result is nil. As a rule, sympathetic fibrinous uveitis 
leaves the eye soft and sightless, with detached retina and opaque media. 

3. Sympathetic Papilloretinitis, which is frequently present as an 
accompaniment of sympathetic uveitis, is in rare instances the sole mani¬ 
festation of sympathetic ophthalmitis. The papillitis is of moderate de¬ 
gree; the papilla may be slightly more prominent than normally; its 
outlines are blurred, and its color is either more grayish or more red than 
under normal conditions. The surrounding retina is somewhat opaque and 
swollen, and sometimes it shows small hemorrhages. The arteries are 
either of normal or of increased size; the veins are broadened and tortuous. 
Visual acuity is usually only moderately reduced. In only 1 of 17 cases 
recorded by Schirmer was vision reduced to counting fingers at three or four 
feet. The visual field may be of normal extent, but usually it is contracted. 
The color-sense is generally normal. The prognosis of sympathetic papillo¬ 
retinitis is favorable, provided it is not the forerunner of the generalized 
form of sympathetic ophthalmia. The treatment comprises enucleation 
of the exciter, when indicated; the local use of atropin; and the internal 
use of mercurials. 

4. Other Sympathetic Afeections have been described, but have 
not gained recognition among modern ophthalmic writers. Thus, sympa¬ 
thetic optic-nerve atrophy, sympathetic cataract, sympathetic detachment of 
the retina, and conjunctivitis, keratitis, scleritis, and canities have been 
recorded. At the present time there exist no good reasons for considering 
these conditions as sympathetic affections. 

Prognosis.—From what has been written it will be apparent that the 
prognosis of sympathetic fibrinous uveitis—to which class most cases of 
sympathetic ophthalmitis belong—is exceedingly grave. Bandolph, writing 
in 1898, was able to gather from literature only 19 cases of well-established 
recoveries. Gumpper, in the same year, in an inaugural dissertation, re¬ 
corded 65 cures, of which only 25 had been examined one year after the 
cessation of inflammatory symptoms. Schirmer, who had 5 recoveries in 
35 cases, thinks the disease less severe to-day than in former times. Surely 
prevention of this disease is much more important than therapeusis. As 
regards the form of sympathetic ocular disease present, the greater the 
fibrinous exudation and the thicker the iris, the more unfavorable is the 
prognosis. Uveitis serosa offers a favorable prognosis and the same is true 
of sympathetic papilloretinitis. The prognosis also is favorable in cases 
where sympathetic ophthalmitis has developed after removal of the exciter. 

Pathology.—While it is not feasible to discuss the pathologic anatomy 
of sympathetic irritation, that of sympathetic inflammation is of great in¬ 
terest. As is clear, the changes in the exciting eye are much better known 
than those of the sympathizer, but, as far as our knowledge goes, it can be 
stated that they are identical in both cases. 

The findings in all cases of more chronic, fibrinous uveitis are these: 


602 


MODERN OPHTHALMOLOGY. 


All of the three portions of the uvea contain disseminated agglomerations 
of lymphocytes (round cells), which are accompanied, in cases of severe 
inflammation, by a diffuse infiltration of the whole tissue with the same 
type of cells. After disappearance of the inflammatory process the charac¬ 
teristic structure of the uvea is lost, and instead a pigmented connective 
tissue, poorly supplied with blood-vessels, is encountered. Besides this, the 
iris and the ciliary body are covered with a copious fibrinous exudate, which 
strongly tends to organization, while the chorioid never produces such an 
exudate. 

Usually the infiltration of the iris is more or less diffuse, while in the 
ciliary body the most pronounced infiltration occurs in the space between 
the muscular and the pigmentary layer. In the chorioid the main seat of 
the process is the layer of the large vessels and in the suprachorioidea, while 
the inner layers, and especially the capillary layer, are not at all or only 
slightly affected. It is interesting to state that in the chorioid very often 
tubercle-like formations with giant cells are found, which, however, have 
nothing to do with tuberculosis. 

Comparatively slight are the changes in the optic nerve, papilla, and 
retina. In the latter atrophy of the nervous elements and slight increase 
of the supporting tissue occurs. The papilla often shows an edematous 
infiltration, but seldom an extensive cellular infiltration, while the latter 
is often very pronounced in the optic nerve. The episcleral vessels are 
hyperemic and the tissue around them is loosened and edematous. In the 
blind end of the subvaginal space of the exciter often a dense infiltration of 
small round cells is present. 

The bacteriologic findings in this disease are of a very contradictory 
nature. In a number of cases bacteria have been found, most often the 
staphylococcus pyogenes albus, but in no case has the proof been established 
that a certain bacterium has been the cause of the sympathetic inflammation. 
By this, however, it is not meant to say that sympathetic ophthalmitis is 
not of bacterial origin. Further investigations are necessary. 

Pathogenesis.—The limits of this work prohibit an exhaustive account 
of the various experiments which have been made and the theories which 
have been advanced to account for the transmission of disease from the ex¬ 
citer to the sympathizer. It is definitely settled that the pathogenesis of 
this process cannot be determined by experiments made on the lower ani¬ 
mals. The old theory of reflex action via the ciliary nerves has been aban¬ 
doned, and modern ophthalmologists favor the view that sympathetic 
ophthalmitis is of bacterial origin, but the germ remains to be found. It is 
supposed that the infection spreads along the sheath of the optic nerve to 
the chiasma, and thence along the sheath of the other optic nerve. The 
bacteria theory of sympathetic ophthalmitis cannot be considered as estab¬ 
lished until the specific organism shall have been identified. One fact 
which tends to disprove the theory of direct transmission is this: that the 
infiltration becomes less and less toward the chiasma. 


SYMPATHETIC EYE DISEASES—ENUCLEATION. 


G03 


Although we do not know with certainty to-day in what way the 
healthy eye is involved in inflammatory changes through the disease of the 
other eye, the theories attempting an explanation are numerous. Leaving 
aside the theory of sympathetic irritation (transmission of a nervous irrita¬ 
tion through the course of the ciliary nerves), only those hypotheses shall 
be mentioned which deal with inflammation of the sympathizer. 

1. Nerve Theories. — - 1 . Optic-Nerve Theory .—The assumption was 
that, owing to the well-known crossing of the optic fibres, the inflammatory 
process, arriving at the chiasma, was from there transmitted along the optic 
nerve of the other eye. This view, assuming the reflection of an irrita¬ 
tion which caused inflammation, according to modern physiologic knowl¬ 
edge appears untenable. 

2. Ciliary-Nerve Theory .—This theory supposes that, in the sympa¬ 
thizing eye, an irritative condition of the ciliary nerves is produced which, 
in a manner as yet unknown, is transmitted to it and causes here a condition 
of irritation that gradually leads to inflammation. Muller based this 
theory on merely anatomic reasons. More important are certain clinical ob¬ 
servations. Closer consideration, however, shows that this theory cannot 
be sustained. 

II. Bacteria Theories. —With the advent of bacteriology, and with 
the observation that the majority of ophthalmias are accompanied by bac¬ 
terial growth, theories have been advanced to explain sympathetic inflam¬ 
mation. The oldest one is that of transmission by metastasis, which was 
advanced by Berlin. He inferred that the bacteria of the primarily dis¬ 
eased eye obtained access to the general circulation, thus being brought to 
the uvea of the other eye. Here, finding a congenial soil, they were said 
to become the cause of the sympathetic disease. Arnold believed that, by a 
retrograde way through the venous channels, the propagation occurred; 
while still others, with Leber, thought that the trouble of the sympathizer 
was accomplished by a continuous growth of the infecting microbe along 
the lymph-vessels. Schmidt-Bimpler has been a strong advocate of this 
theory; but it must be remembered that, as yet, in no case scientifically 
studied has the evidence been established for one or the other mode of propa¬ 
gation. Direct experiments always have had a negative result. 

III. Combined Theories, mainly advanced by E. Meyer and Schmidt- 
Bimpler, attribute to primary irritation of the ciliary nerves the possibility 
that pathogenic microbes can find in the tissues innervated by these nerves 
a suitable soil. Unfortunately very many clinically well-observed facts ab¬ 
solutely cannot be reconciled with this view. For instance, the observation 
that after an injury to one eye sympathetic inflammation of the other eye 
never occurs within less than fourteen days. In the same way, this theory 
leaves the fact unexplained that, after enucleation of one eye, the sympa¬ 
thetic affection of the other can occur as long as many weeks later. 

IV. Toxin Theories. —Sympathetic inflammation is not caused by a 
transmigration of the microbes themselves, but only by that of the products 


604 


MODERN OPHTHALMOLOGY. 


of their metabolism. What speaks most against this explanation is that, 
even after extirpation of the primary focus, the inflammation pursues its 
ordinary course in a great number of cases, while in intoxications the effect 
of the toxin gradually lessens, as its amount is diminished. This theory 
affords a satisfactory explanation only for the pure papilloretinitis sympa¬ 
thetica, while it certainly cannot be applied to the ordinary cases. 

Prophylaxis.-—The prevention of sympathetic ophthalmitis is much 
more feasible than its cure, and efforts in this direction should begin imme¬ 
diately after the receipt of an injury. The strict aseptic treatment of all 
wounds should be followed, but unfortunately it will often happen that 
the wound is infected before the surgeon is consulted. 

In cases of injury which cannot remain under the constant observation 
of an ophthalmic surgeon, the general practitioner should make daily tests 
of the vision of the good eye, since failure of vision is the one symptom 
likely to attract the attention of the non-expert. 

Prophylactic measures are:— 

1. Preventive Enucleation. —Prophylactic enucleation is indicated 
whenever there exists a uveitis of bacterial origin which does not yield to 
proper treatment in reasonable time. 

2. Prophylactic Exenteration may take the place of enucleation; 
but for two reasons (infection of the stump of the optic nerve and the possi¬ 
bility of leaving portions of the uvea behind) this method is not perfectly 
reliable. 

3. Prophylactic Neurotomy (opticociliary) has not proved to be 
a sufficient protection. 

4. Resection of the Optic and Ciliary Nerves does not furnish 
a sufficient protection for the other eye. 

The normal operation remains, up to date, the enucleation. Exentera¬ 
tion should be restricted to panophthalmitic bulbs, while neurotomy ought to 
be altogether abandoned. 

The most certain of all prophylactic measures is the removal (enuclea¬ 
tion) of an injured eye, subject to the rules governing this operation. If 
the second eye remains well for a period of four weeks after enucleation, the 
prophylaxis is practically absolute. 

Treatment.—The indications for treatment of sympathetic ophthalmitis 
are (1) removal of the exciter if blind and (2) the use of remedies to con¬ 
trol the inflammatory process in the sympathizer. 

1. Removal of the exciter, in a case where sympathetic ophthalmitis 
is fully developed, is not to be considered, if the exciter possesses useful 
vision. In case there is perception of light, but the eye has remained 
hypotonic for several weeks, or where corneal opacity is so extensive as 
to preclude the possibility of the restoration of useful vision, an enucleation 
of the exciter will be in order. Attempts to improve the condition of the 
exciter by making broad iridectomies have generally proved unsatisfactory. 
If tension is increased, it is better treated in these cases by paracentesis of 


SYMPATHETIC EYE DISEASES—ENUCLEATION. 


605 


the cornea or by sclerotomy. If an enucleation of the exciter is not in 
order, it should be treated with atropin, hot compresses, and possibly sub¬ 
conjunctival injections of bichlorid of mercury (1 to 2000). 

2. Treatment of the sympathizer includes local and general measures. 
Atropin should be used three times a day, and the patient should be kept in 
a dark-room during the more acute period of his disease. 

The intra-ocular injection of antiseptics, as advised by Abadie, is gen¬ 
erally condemned by American and German surgeons. The subconjunctival 
injection of mercuric bichlorid seems to have been beneficial in a few cases. 

The internal use of large doses of salicylate of sodium—120 to 180 
grains daily in divided doses, fortified by the simultaneous use of brandy— 
has given good results in the hands of Gifford, who regards it as the most 
important remedy. Heuse has recorded several cases which were favorably 
influenced by the daily use of GO to 75 grains of the same remedy. Aspirin, 
in 15-grain doses, four or five times a day, may be substituted for salicylate 
of sodium. 

The older surgeons placed their trust in large doses of mercurials given 
by the mouth or by inunction. Schirmer gives the first place to mercury. 
Small doses of calomel, frequently repeated, seem to be of value. The local 
application of heat in the form of poultices, frequently changed, has been 
advised by Gifford. 

Hypodermic injections of pilocarpin sometimes do good and should 
be tried. 

Sympathetic papilloretinitis should be treated locally with atropin, 
dark glasses, correcting lenses, and the use of hot compresses. Internally 
mercury or iodid of potassium should be administered. Pilocarpin may 
be used advantageously. It is inadvisable to keep these cases in a dark¬ 
room unless other evidences of sympathetic ophthalmitis are present. In its 
pure form, sympathetic papilloretinitis offers a favorable prognosis. 

Without exception an operation of any kind will be out of order until 
long after signs of acute inflammation have disappeared. Late in the his¬ 
tory of the case an iridectomy may be of some value. If the chief obstacle 
to vision is an opaque lens, an extraction can be made; or the drilling opera¬ 
tion of Tyrrell or the procedure of Critchett can be tried. In Critchett’s 
operation two cataract-needles are used. One holds the lens fixed while the 
other makes a small tear in the capsule. The points are then separated 
to enlarge the rent. Some lens-matter escapes and usually there is no re¬ 
action. The operation is repeated at intervals of a few weeks until the lens 
is absorbed. Critchett, Story, and Oliver have practiced this operation with 
success. 

TyrrelFs operation is performed with one needle. It is passed 
through the cornea near its outer part. It is then made to penetrate the 
anterior capsule (taking care not to injure the iris) to the depth of one 
millimetre. The handle is then rotated so that the instrument will act as 
a drill. The operation can be repeated several times at intervals of a month. 


606 


MODERN OPHTHALMOLOGY. 


INDICATIONS FOR ENUCLEATION. 

Indications for enucleation are furnished either by the condition of the 
eye or by the state of the orbit. 

I. Among the ocular reasons for enucleation, evisceration, or Mules’s 
operation, or one of the modifications of these procedures, are the follow¬ 
ing (modified from Czermak) 

1. In recent severe wounds, in which the cornea or sclera is lacerated and 
the intra-ocular contents are partly or wholly lost; wounds which destroy 
the possibility of restoration of useful vision; wounds with the lodgment of 
a foreign body which cannot be removed. However, many lacerations of 
the cornea and some scleral wounds, if not infected, admit of recovery under 
proper treatment. The prolapsed iris or vitreous is to be cut off, the scleral 
wound is to be approximated with sutures, the injured lens is to be ex¬ 
tracted, etc. 

2. In all conditions liable to produce sympathetic ocular disease, the 
offending eye, if blind, is to be removed. Such conditions include irido¬ 
cyclitis, iridochorioiditis, with shrinking of the globe; suppurative inflam¬ 
mation following wounds, operations, or the lodgment of foreign bodies; 
perforating corneal ulcers with iridocyclitis. 

3. In cases where sympathetic irritation or inflammation has already 
appeared in the “good” eye, provided the exciter is blind, or possesses only 
a limited amount of vision. Here the differences between sympathetic irri¬ 
tation and inflammation are clear-cut: enucleation cures sympathetic irri¬ 
tation, while it has little or no influence over sympathetic ophthalmitis. 
If the exciter possesses useful vision, and sympathetic ophthalmitis has al¬ 
ready developed, the removal of the exciter is not to be considered, since, 
after the case has run its course, the probabilities are that the exciter will 
possess the better vision of the two. 

4. In uncontrollable hemorrhage from an injured eye, even if the 
wound is small. This occurs at times in degenerated globes (total ectasia, 
glaucoma, hydrophthalmos). 

5. In spontaneous chronic iridocyclitis with atrophy of the globe; in 
glaucoma with degeneration of the ocular tunics; in eyes blind from de¬ 
tachment of the retina or luxation of the lens, provided the patient suffers 
from annoying photopsia or loss of sleep from pain and recurring attacks 
of inflammation. 

6. In general enlargement of the globe through thinning of the sclera 
(total ectasia of the bulb). 

7. In ulceration of the cornea appearing in an eye with total staphy¬ 
loma or in an eye which has undergone degenerative glaucoma. These 
conditions lead to rupture, hemorrhages, panophthalmitis, or insidious 
iridocyclitis. 

8. In all malignant intra-ocular tumors where complete extirpation 
cannot be performed. This concerns all tumors of the retina, ciliary body, 


SYMPATHETIC EYE DISEASES—ENUCLEATION. 


607 


and chorioid, and those tumors of the iris which involve the margin of the 
ciliary body. Small tumors of the iris, so situated that they can be entirely 
removed, are to be subjected to iridectomy. 

9. In all epibulbar malignant tumors whose attachment to the globe is 
so close as to render removal of all the growth incompatible with the in¬ 
tegrity of the eye, or tumors in which the orbital tissues are also involved. 

10. In primary conglobate tuberculosis (granuloma) of the iris and 
chorioid. 

11. In all cases of phthisis bulbi where there is shrinking pain on 
pressure. 

12. In cases where other operations (opticociliary neurectomy, ex¬ 
cision of the cervical sympathetic for relief of pain in glaucoma) have failed 
to relieve suffering, the eye being blind. 

13. In panophthalmitis. 

II. The orbital indications for enucleation are:— 

1. Inoperable tumors encroaching on the walls of the orbit, producing 
exophthalmos and lagophthalmos, and leading to destruction of the globe by 
painful suppurative inflammation. 

2. In orbital cellulitis, if the eye is already lost and the surgeon believes 
that life will probably be saved by the operation. 

. ENUCLEATION AND ITS SUBSTITUTES. 

Removal of the eyeball, either complete (as in enucleation) or partial 
('as in Mules’s operation, Hall’s operation, or their modifications), is to 
be done under general anesthesia, unless the condition of the patient is such 
that the inhalation of chloroform or ether will be dangerous. In old alco¬ 
holics, for example, general anesthesia is dangerous and may be replaced 
by the local use of cocain or holocain, aided by the use of adrenalin or 
suprarenal solution. These remedies can be dropped on to the conjunctiva, 
and, after this membrane is incised, further use can be made of the solu¬ 
tions before the next step is taken. Some surgeons prefer to inject the 
solution into the orbital ’tissues by an hypodermic syringe. This method 
may cause great depression, cold perspiration, or syncope, while dropping 
cocain in the wound, as the operation proceeds, is tedious and often unsatis¬ 
factory. In this manner the parts can be sufficiently anesthetized, there 
being little or no pain, except at the moment of cutting the ciliary nerves 
surrounding the optic nerve. In case of evisceration (Mules’s operation) 
the pain is practically nil under holocain or cocain. Before enucleation 
the conjunctiva and skin of the lids and adjacent parts are to be thoroughly 
cleansed with soap, water, and bichlorid solution. After the globe has 
been removed, it is well to flush the orbit with hot sterile water or with 
bichlorid solution. 

Technique of Enucleation.—Of the various methods of enucleation two 
« are in common use, viz.: Bonnet’s method and Arlt’s modification. 


603 


MODERN OPHTHALMOLOGY. 


Bonnet's Method. —The object of this operation is the removal of 
the eyeball without injury to Tenon’s capsule. The instruments required 
are a speculum, tissue-forceps, fixation-forceps, scissors, strabismus-hook, 
curved enucleation scissors, needles, suture material, and needle-holder. 
The speculum having been introduced, and the eyeball being held by an as¬ 
sistant, the surgeon rapidly separates the conjunctiva from around the 
cornea, and dissects it back as far as the insertions of the recti muscles. 
The tendons are lifted up, one at a time, by the strabismus-hook, and are 
cut off close to their insertions. The subconjunctival tissue is likewise lifted 
up by the hook. The next step is to dislocate the globe forward by pressing 
the speculum backward, this being done so as to facilitate the cutting of the 
optic nerve. This is accomplished by means of long, curved scissors, which 
are held closed and are passed backward until the nerve is felt as a tense cord. 
The blades are then opened, the nerve engaged, and cut close to the sclera. 
The globe is then held in the left hand and the oblique muscles are severed, 
together with the ciliary vessels, nerves, and any adhering tags of tissue. 
The operation is completed by the use of a purse-string suture, passed 



Fig. 354.—Enucleation scissors. 


through the conjunctiva and through each of the recti tendons. Some 
operators, after cutting all other muscle attachments close to the sclera, 
leave a piece of the tendon of the external rectus muscle attached to the 
globe, and hold it with fixation-forceps to steady the eye while cutting the 
optic nerve. The dusting of iodoform or boric acid into the conjunctival sac 
and the pouch, left by removal of the eye, is unnecessary. 

In cases requiring resection of the optic nerve back to the foramen 
opticum, Bonnet’s method is somewhat modified. After removal of the 

t 

globe, as described above, the surgeon feels for the stump of the optic nerve 
with his right index finger, and grasps the nerve with fixation-forceps held 
in the left hand. After seizing the nerve-stump he cuts it off at the apex 
of the orbit by means of carved, blunt-pointed scissors. 

Arlt's Method.— This operation requires a speculum, toothed forceps, 
and scissors. The tendon of the internal rectus muscle is seized with the 
overlying conjunctiva and the grasp is retained until the end of the opera¬ 
tion. The muscle is cut external to the forceps. Through this opening 
one blade of the scissors is passed under the inferior and superior recti 
tendons, which are severed in succession. Then the optic nerve is cut, the # 







SYMPATHETIC EYE DISEASES—ENUCLEATION. 


609 


globe being drawn forward and turned outward to facilitate the section. 
Last, the external rectus and the two oblique muscles are severed close to 
the globe and the operation is finished. The purse-string suture may be 
used or not, as the operator desires. The author favors its use, believing 
that the conjunctival suture aids primary union and often prevents the for¬ 
mation of a button of “proud flesh.” It is well not to draw the suture too 
tightly, since blood may accumulate behind it and cause great pain. Many 
operators place a small piece of gauze in the orbit before tying the suture. 
This gauze is changed daily for a week. The dressing used is dry gauze and 
a bandage. 

Arifs method is exceedingly rapid, but it is not suited to eyes whose 
walls are weak, since the pressure used in the operation will cause rupture 
of the globe and escape of the contents, increasing the danger of infection. 

Among the accidents, mistakes, and sequel® of enucleation are the fol¬ 
lowing :— 

1. Removal of the Good Eye has occurred in at least one instance of 
which the author has received reliable information. In a case in which the 
pathologic condition does not show externally—as, for example, an intra¬ 
ocular tumor—it will be advisable for the surgeon to make a mark on the 
lid of the eye to be removed. 

2. Hemorrhage, usually insignificant after enucleation, has led to 
death in a few instances in bleeders and old alcoholics. Usually pressure 
by the finger at the apex of the orbit will stop it, and the compress bandage 
will prevent its recurrence. 

3. Inability to Deliver the Globe may occur because of smallness 
of the palpebral fissure, which, of course, must then be enlarged; but usually 
the surgeon will find that the optic nerve has not been severed. 

4. Extension of Disease beyond the Globe is often encountered in 
malignant growths which have perforated the eye posteriorly and have 
involved the optic nerve and adjacent tissues. Here the optic nerve must 
be resected back to the foramen opticum, and all infected tissue should be 
removed from the orbit. 

5. Perforation of the Globe may occur even in the hands of a care¬ 
ful surgeon, if the sclera is unusually thin. The operation is to be finished, 
all escaping liquids being carefully wiped away and the orbit thoroughly 
flushed with bichlorid solution. If the globe collapses, the operation is to be 
finished by careful dissection, the eye being held with a sharp hook. Such 
an accident is not uncommon after perforating wounds, ulcers, or tumors. 

6. Panophthalmitis with Orbital Thrombosis, producing a hard, 
lardaceous condition of the orbital tissues, may confuse the operator. Here 
the surgeon has simply to follow the outline of the thickened sclera to 
remove the globe. 

7. Occipital Pain and Eccfiymosis of the Lids are sometimes seen 
after the most careful enucleation. The pain stops in a few hours and 
the ecchymosis disappears in ten days. 

39 


610 


MODERN OPHTHALMOLOGY. 


8. Orbital and Palpebral Abscess, following enucleation, are rare 
complications. They are to be treated on general surgical principles. 

9. Fatal Meningitis after enucleation is of rare occurrence. The 
author has never seen a case, although he does not hesitate to enucleate 
panophthalmitic eyes. It is due to infection either by extension of germs 
of panophthalmitis to the sheath of the optic nerve, and thence to the brain; 
tir to unclean instruments, sutures, solutions, gauze, or fingers; or to con¬ 
tact with pus from the eye by rupture of the globe during the enucleation, 
or from pus derived from the tear-sac. Von Graefe, who lived before the 
era of aseptic surgery, observed meningitis twice after enucleation of panoph¬ 
thalmitic eyes, and advised against the operation. Most modern ophthal¬ 
mologists, however, do not hesitate to enucleate them, thus greatly relieving 
pain and suffering and shortening the period of treatment. Some surgeons, 
however, think best to eviscerate the globe in panophthalmitis. If an 
orbital phlegmon exists with meningitis, Noyes advises that deep incisions 
be made to let out the pus, and deep irrigation with strong antiseptics is to be 
used. If meningitis occurs after enucleation, it is not necessarily fatal, 
although the condition is very serious. 

In 1896 a committee of the Ophthalmological Society of the United 
Kingdom investigated this subject. Of 10,734 cases of simple excision, in 
7 fatal meningitis ensued; in all of these the eye which was removed was 
suffering from suppurative panophthalmitis. It is not certain that the 
operation caused the meningitis, since cases of panophthalmitis have been 
recorded in which the eye was not removed and meningitis has occurred. 
One case of fatal meningitis has followed evisceration. Since this operation 
has been much less frequently performed than enucleation, it is an open 
question which operation is freer from risk. The committee could learn of 
no case of meningitis following Mules’s operation or the insertion of an 
artificial globe into Tenon’s capsule. The author has had one death during 
enucleation under chloroform anesthesia which was due to the fact that an 
arrow-shaped piece of steel had pierced the globe, had passed into the 
sphenoidal fissure, and had injured the brain. 

Technique of Evisceration.—The instruments required are speculum, 
fixation-forceps, scalpel, scissors, scoop, suture material, needles, and needle- 
holder. The speculum being in place and fixation-forceps holding the globe, 
the scalpel is used to puncture the sclera at a point five millimetres posterior 
to the corneoscleral junction. Into this opening one blade of the scissors 
is introduced, and a cut is made concentric with the cornea. Thus, the an¬ 
terior segment of the globe is removed. The iris, ciliary body, chorioid, lens, 
and vitreous humor are removed with the scoop or spoon. Tags of chorioid 
and retina will adhere to the venae vorticosae and nerve-head. Such adherent 
pieces can best be removed by wiping with gauze held in forceps, which are 
rotated rapidly within the globe. The circular wound is now altered by 
removing small triangular pieces of sclera at the insertions of the external 
and internal recti muscles. The cavity is irrigated with sterile water or 


SYMPATHETIC EYE DISEASES—ENUCLEATION. 611 

with a biclilorid solution, and the wound is closed by five or six sutures 
passed through conjunctiva and sclera. A gauze dressing and compress 
bandage are applied. Healing is usually uneventful, but Knapp has re¬ 
ported a case of evisceration followed by thrombosis of the vorticose and 
orbital veins. There is frequently marked chemosis following this opera¬ 
tion. The sutures are removed on the seventh or eighth day. 

Evisceration with Insertion of an Artificial Vitreous (Mules’s Opera¬ 
tion).—This operation is simply an evisceration plus the placing of a hall 
of glass or metal (gold) within the scleral cup. To facilitate the introduc¬ 
tion of the artificial vitreous, the introducer of Mules or that of Todd is 
used (Fig. 355). The globe should not be so large as to stretch the sclera 
when sutures are introduced. Two sets of sutures are to be used: the scleral 
ones are directed vertically and when tied present a horizontal scleral Avound, 
while those through the conjunctiva are passed horizontally and when tied 
the conjunctival wound is vertical. Catgut is used for sewing the sclera, 
and silk for the conjunctiva. A pad of gauze and a firm compress bandage 



Fig. 355.—Artificial-vitreous introducer. (Todd.) 


are applied and reapplied during the period of swelling. There is always 
considerable swelling and some pain for several days after this operation. 
The success of Mules’s procedure demands rigid attention to asepsis. The 
cosmetic results are beautiful, since the rotations of the artificial eye, placed 
on the stump, exceed those obtained after enucleation. Furthermore, the 
natural contour of the lids is retained, and there is an absence of the annoy¬ 
ing conjunctival secretion which follows the wearing of a shell after enuclea¬ 
tion. In the author’s cases the artificial eye was inserted two or three weeks 
after operation. The globe is extruded in from 12 to 15 per cent, of the 
cases. Once the wound is firmly closed, it does not, as a rule, subsequently 
reopen, but it has been known to do so as late as se\ r en years after the inser¬ 
tion. No case is recorded in which the glass globe has broken in the sclera. 
Silver globes ha\ T e sometimes produced argyrosis of the stump. 

Sclero-optic Neurectomy (Hall's Operation).—This operation, which 
originated with Dr. Ernest Hall, of Victoria, B. C., consists of an eviscera¬ 
tion to which is added an excision of the posterior part of the scleral cup 
and resection of the optic nerve. Affer cutting aAvay the sclera to an extent 






612 


MODERN OPHTHALMOLOGY. 


sufficient to include the ciliary body and eviscerating the globe, the speculum 
is inserted within the ball, thus holding both lids and edges of the sclera 
open. “The point of entrance of the optic nerve is then grasped with two 
forceps and the scissors inserted as close to the nerve as is possible to avoid 
wounding of the ciliary arteries, and a circular incision is made in the 
sclerotic, freeing the optic nerve, which is then drawn forward and severed 
about ten millimetres from the sclerotic junction, thus removing a section of 
the optic nerve. The sclerotic and conjunctiva are closed vertically to give 
normal tension to the internal and external recti, as lateral movement is of 
greater importance than vertical. After the artificial eye is adapted there 
is perfect movement within thirty-five degrees laterally and twenty degrees 
vertically.” This operation has been modified by Huizinga, who removes a 
larger section of the posterior scleral cup, cuts and removes the optic and 
ciliary nerves, and inserts an artificial vitreous. He has named this opera¬ 
tion eviscero-neurotomy. 



Fig. 356.—Sclero-optic neurectomy. 

The tissues anterior to the curved line, A-B, are to be removed. Jt-Z, Incision in posterior part 
of the sclera, i-r, Part of the optic nerve to be excised. 

Implantation of a Sphere into Tenon’s Capsule (Adams Frost's Opera¬ 
tion).—This operation was done by Frost in 1886, as follows: “The 
conjunctiva having been divided in the usual way, each rectus muscle in suc¬ 
cession was seized with forceps, divided, and secured by a ligature passed 
through it and through the conjunctiva; the enucleation was then com¬ 
pleted, the four recti being held apart by means of the sutures. Mules’s 
sphere was introduced into the capsule of Tenon without any difficulty; 
opposite recti, with the conjunctiva, were then united across it by passing 
one of the ligatures through the'opposite tendon, the other ligature being 
then removed.” This operation has been practiced by Lang, who unites 
Tenon’s capsule horizontally by three silk sutures and then sews the con¬ 
junctiva separately. Other modifications have been made by Morton, of 
Minneapolis, and Oliver, of’Philadelphia. The sphere can be made of glass, 
celluloid, silver, or gold. Fenestrated aluminum spheres were proposed by 
Bryant, of Omaha. 


SYMPATHETIC EYE DISEASES—ENUCLEATION. 


613 


Immunity to Sympathetic Ophthalmitis.—The comparative value of 
these operations as regards immunity to sympathetic ophthalmitis was in¬ 
vestigated in lb96 by a committee of the Ophthalmological Society of the 
United Kingdom. The committee found no case of sympathetic inflamma¬ 
tion following simple evisceration (von Graefe’s operation), but gives de¬ 
tails of five cases after Mules’s operation. In all of these, however, the eyes 
had received injuries likely to produce the sympathetic disease, which is 
probably to be attributed more to the injuries than to the operations. The 
committee found no evidence to show that the insertion of an artificial globe 
into 1 enon s capsule lessens the immunity which excision confers. Cases 
are detailed of sympathetic ophthalmitis following opticociliary neurectomy 
and neurotomy. Since these operations are practiced to a limited extent, 
it is inferred that they are not so valuable as enucleation in preventing 
sympathetic ophthalmitis. Abscission affords less immunity than enuclea¬ 
tion. 

As regards sclero-optic neurectomy, Hall claims the following advan¬ 
tages: “1. The volume of the pad due to the preservation of a considerable 
amount of tissue. 2. r l he extensive movement of the pad owing to the 
muscular attachments being left undisturbed. 3. The slight risk of para¬ 
lyzing the muscles during the operation, through injury to the third and 
sixth nerves. 4. The absence of any tendency to sympathetic disease of 
remaining eye, on account of removal of the ciliary region in front, and 
the sclero-neural connection behind.” 

The Advantages of Mules’s Operation versus Enucleation have been 
presented by Bickerton as follows:— 


Enucleation. 

1. Complete removal of the globe and its 

contents. 

2. No stump; therefore sunken eye. 

3. Disturbance of all muscular relations 

and arrest of movement. 

4. A fixed, staring eye attracting atten¬ 

tion. 

5. Patient shuns society. 

6. Arrested development of orbit in case 

of children. 


Mules’s Operation. 

1. Retention of the frameworks of the 

eye. 

2. A firm, round globe forming perfect 

support for an artificial eye. 

3. Perfect harmony of muscular move¬ 

ments retained. 

4. Fitted with a selected eye it defies 

detection. 

5. No qualms as to personal appearance. 

6. No interference with growth of orbit. 


OCULAR PROSTHESIS. 

The insertion of an artificial eye to cover the defect caused by atrophy 
or deformity of the globe, or after an operation of the eyeball, is called 
ocular prosthesis. 

After an enucleation or one of its substitutes has been made, it is advis¬ 
able that the patient should wear an artificial eye. This should be inserted, 
and worn daily, as soon as the tissues will tolerate its presence. If an 
enucleation has been made, there is considerable sinking of the soft parts at 



614 


MODERN OPHTHALMOLOGY. 


the base of the orbit. To obtain the best cosmetic result, under these cir¬ 
cumstances, the artificial eye should be of considerable thickness and should 
be fitted accurately to the soft parts. Formerly, when artificial eyes of a 
shell form were worn, the cosmetic results of an enucleation were often 
unsatisfactory. Since the advent of the thick, or “reform,” eyes the results 
have been much more satisfactory. After a Mules operation only the shell 
form of artificial eye is necessary. 



Fig. 357.—Sphere in position. (Fox.) 

To insert an artificial eye the patient should raise the upper lid, rest¬ 
ing the hand flat upon the forehead; then the eye is pushed beneath the 
upper lid and, while held in this position, the lower lid is pulled downward, 
thus admitting the eye to the socket. Insertion of the eye will be facilitated 
by smearing it with white vaselin. To remove an artificial eye the lower 
lid is to be pulled downward; then the head of a pin or the small end of a 
bodkin is passed beneath the lower edge of the eye; gentle traction will now 
lift the eye from its bed and it can be caught in the hand. 



Fig. 358.—Conformer. (Fox.) 

The dotted lines show the different sizes of conformer. 


The artificial eye should be removed before retiring. It should be 
wiped dry, but should not be placed in water, since sudden changes in tem¬ 
perature will produce minute fissures. The life of an eye is about two vears. 
When it becomes eroded it should be superseded by a new one. The best 
eyes are made of glass. Celluloid eyes are cheaper, but are not satisfactory. 
If the socket becomes irritated, the eye should not be worn for a day or two 
and antiseptic washes should be used. It is necessary that the eye shall fit 
properly. Improperly fitted eyes may cause sympathetic irritation or in¬ 
flammation. 









SYMPATHETIC EYE DISEASES—ENUCLEATION. 


615 


Operation for the Better Support of an Artificial Eye.—Fox has de¬ 
vised the following operation for the better support of an artificial eye in 
cases where an enucleation has been made at some previous time: An 
incision, slightly less in extent than the diameter of the gold hall to be 
inserted, is made through the conjunctiva and tissues of the orbit. The 
upper lid of the conjunctiva is raised, and, with sharp-pointed curved 
scissors, the conjunctiva and such connective tissues as lie close to it are dis¬ 
sected off in all directions around the incision, making a pouch into which 
the glass ball will fit. The edges of the conjunctiva are brought together 
over the ball and are held by five or six stitches. The sphere is retained in 
position by a shell, or “conformer,” which is left in place for twenty-four 
hours. In a few days the artificial eye is fitted and can be worn with com¬ 
fort. Such objectionable features as retained secretion, immobility, and 
sunken appearance are absent. 

Injection of Paraffin after Enucleation has been practiced by Ramsay, 
of Glasgow. The enucleation is made as in the ordinary manner except 
that each rectus tendon is sutured to the conjunctiva before the mus¬ 
cle is severed from the eyeball. After removal of the eye the capsule 
of Tenon is packed with gauze while a purse-string suture is inserted into 
the conjunctiva. The gauze is then removed and, while the recti muscles 
are put on the stretch, melted paraffin is injected into the space formerly 
occupied by the globe. The muscles are united by catgut sutures, the con¬ 
junctival suture is tied, and a bandage is applied. The result is a movable 
stump on which the artificial eye can be fitted. Ramsay reports 4 failures 
in 22 cases. 

Operations for Prosthesis in Cicatricial Orbit.—Occasionally cases occur 
in which, owing to lime burns, trachoma, etc., cicatricial bands prevent the 
insertion and wearing of an artificial eye. Operations for the relief of this 
condition are numerous and most of them are unsatisfactory. Incisions do 
no permanent good. Lining of the enlarged cavity with half-skin flaps 
(Thiersch flaps cut very thick) has given fair results in Gifford’s hands. 


CHAPTER XIX. 


DISEASES OF THE ORBIT. 

By WILLIAM T. SHOEMAKER, M.D., of Philadelphia, 

Assistant Ophthalmologist and a Chief of Clinic to the German Hospital; Dispensary Ophthalmic Surgeon 
to the Presbyterian Hospital; Oculist to the Pennsylvania Institution for the Deaf and 
Dumb ; Associate Member of the American Ophthalmologic Society. 


The orbit is subject to congenital anomalies, tumors, inflammations, 
and injuries. 

CONGENITAL ANOMALIES. 

Congenital anomalies of the orbit are found as various degrees of altera¬ 
tion in the size and shape of this cavity, with a corresponding influence upon 



Fig. 359.—Cyclops. (After Van Duyse.) 

the orbital contents. The defect may be unilateral or bilateral; or, falling 
within the field of teratology, all degrees of anterior dichotomy or of fusion 
may result in the formation of one, three, or four, orbits. 

A two-headed monster would, of course, have four orbits. A double- 
faced monster may have four or three according to the degree of duplica¬ 
tion. 

Cyclopia is a condition in which there is but one orbit and a single 
eyeball. The orbit is usually large and quadrangular, and is situated at 
the root of the nose. Immediately above is generally a proboscis. The 
eyeball may be perfectly single or may show degrees of doubling. The older 
theory for this condition is that of Geoffroy St. Hilaire, who believed that 
the rudiments of two orbits at first distinct had fused in the process of 
( 616 ) 


DISEASES OF THE ORBIT. 


617 


development. Hirst and Piersol believe it to be an arrest of development 
of the anterior cerebral vesicle. According to these authors, there is nor¬ 
mally at first material for but one eye, which is later differentiated into 
two. 

The superior wall is sometimes almost vertical, the orbit then being 
abnormally shallow, the eyeball proptosed, and its movements much limited. 
An acquired anomaly, of the size and shape of the orbit, of this character 
is found in those cases in which the eyeball has been removed or destroyed 
in infancy or in early childhood. As the orbit develops pari passu with and 
in proportion to the development of its contents, a loss of the latter is accom¬ 
panied by a cessation of the former. The orbit remains small, tends to 
become horizontally slit-like, and the face develops asymmetrically. 

The Orbital Contents may be congenitally defective or deficient. The 
eyeball may be abnormally small—a condition known as microphthalmos; 
or it may be entirely absent, the anomaly then being anophthalmos. 



Fig. 360/—Anophthalmos. (Author.) 


Microphthalmia eyes may be small, but otherwise normal; or they may 
be cystic, one er more cysts being present as the result of imperfect closure 
of the fetal fissure. These cysts are therefore always situated below, and 
may extend for some distance, even into the lower lid. 

Anophthalmos. —About one hundred true cases of congenital absence 
of one or both eyes have been reported. While the condition is recognized 
clinically, in a strict pathologic sense it rarely, if ever, exists. Cases of this 
anomaly which have been subjected to anatomic examination have generally 
shown the presence of rudimentary eyes. Ten cases are on record in which 
careful dissection failed to show any trace of an eyeball. The condition is 
often associated with the presence of an orbito-palpebral cyst. In cases 
described clinically as unilateral anophthalmos the eye which is present may 
be normal, microphthalmic, nystagmatic, highly hypermetropic, or colobom- 
atous in its iris and chorioid. The lids are generally well formed, but 
may be small and adherent at their margins. The orbits are often smaller 






618 


MODERN OPHTHALMOLOGY. 


than normal. The lacrimal glands are generally present. The puncta and 
canaliculi may be absent. Frequently the rudimentary eye can be felt as a 
small mass deeply placed in the orbit. Yon Hippel has collected 87 cases 
of anophthalmos: i.e., absence of one or both eyes without discernible cyst- 
formation or other evidences of a rudimentary eyeball. Of these, 64 were 
bilateral and 23 were unilateral. 

The Ocular Muscles may be anomalous in origin, insertion, or in struc¬ 
ture. One or more may be entirely absent. A corresponding loss of 
function will then exist. 

Congenital Cysts* of the Orbit are generally dermoid in character, due 
to a fetal invagination of epithelial-producing cells. They lie against the 
orbital periosteum, often in a little depression which they have made for 
themselves. While the most common location is perhaps the nasal side, 
they have been found in all situations, with greater frequency, however, in 
and out. They are smooth, have no very fixed attachments, and upon palpa¬ 
tion their cystic nature can usually be made out. Before operating for their 
removal it is very important to diagnose them differentially from 

Meningocele and Encephalocele, which may be present in the orbit. 
These two conditions are also congenital. The first is a prolapse, or hernia, 
of the meninges with cerebro-spinal fluid contents, projecting through a 
breach in the retaining skull-wall. The second is the same with the addi¬ 
tion of brain-substance prolapsing within the meningeal sac. The bony 
defect is in the line of a suture. It generally involves the junction of the 
ethmoid and the frontal bone, the tumor then presenting at the upper, inner 
orbital angle. Very rarely a posterior orbital meningocele or encephalocele 
presents near the apex of the orbit. Its diagnosis without exploratory 
operation is impossible. The following points must he observed: Meningo¬ 
cele and encephalocele are often reducible, and after reduction the bony 
margin of the aperture through which they came can be felt. Pulsation 
and hemic sounds can be elicited. The size and tension of these protru¬ 
sions are variable, depending upon varying blood-pressure within the cra¬ 
nium. A dermoid cyst will present none of these phenomena. A meningo¬ 
cele may become constricted and its neck obliterated, leaving a complete 
cyst with cerebral fluid contents within the orbit. 

Treatment.—Non-interference must be observed in the treatment of 
meningocele and encephalocele. The treatment of orbital cysts is referred 
to on page 627. 


TUMORS OF THE ORBIT. 

* 

Modern pathology has restricted the term “tumor” within narrower 
limits than have been generally recognized by authors of text-books on 
ophthalmology. Senn defines a tumor as a localized increase of tissue, the 
product of tissue-proliferation of embryonic cells, of congenital or post¬ 
natal origin, produced independently of microbic causes. This definition 


DISEASES OF THE ORBIT. 


619 


excludes inflammatory swellings. It also excludes cysts, which are the 
abnormal dilations of pre-existing tubes or cavities. Dermoid cysts and 
dermoid tumors are to be classified as teratomata, or aggregations composed 
of various tissues, organs, or systems of organs which do not normally exist 
where found. The sharp line drawn is of importance, for, while an in¬ 
flammatory swelling may cause many or all of the clinical symptoms pro¬ 
duced by a tumor, the first may be amenable to internal medication. It is 
said that no authentic case of a neoplasm being so influenced is on record. 
This section will comprise only the true tumors. 

In a case of orbital tumor it is desirable to determine, first, the origin 
of the tumor or that tissue primarily affected; second, the nature of the 
growth, regarding its malignancy or its innocence; and, third, the extent 
to which the adjacent structures have become involved, either mechanically 
or by infiltration. 

Etiology and Location.—Tumors originating primarily in the orbit are 
comparatively rare, but invasion of the orbit by neoplasms originating in 
the sinuses and cavities of the head markedly increases the percentage of 
orbital disease of this character. C. 0. Weber, in an analysis of 1013 cases 
of tumor, found 41 affecting the eyes and orbit, 217 affecting the organs 
of the mouth and the maxillary bones, and 56 affecting the nose, pharynx, 
and antrum of Highmore. A certain number of these extra-orbital tumors 
necessarily found their way into the orbit. Billroth has reported 18 orbital 
tumors in a series of 217 growths occurring in the region of the head. 

In the last few years the use of the Boentgen ray has done much for 
the more ready determination of the extent and origin of some tumors, espe¬ 
cially those of the bones. A sciagraphic comparison of the two sides of the 
head will often show an increase of the size, and alteration in the shape, of 
the individual bones affected. A tumor pushing into the orbit will displace 
the eyeball in front of it. The direction of the displacement of the globe 
is therefore of diagnostic value. Displacement directly forward, due to a 
tumor, is indicative of a location within the muscle-cone (Berry). Mobility 
in toto, if elicited, is evidence presumptive that the tumor is not of the 
orbital wall. Pulsation , when present, is an important symptom, and shows 
that we have a vascular growth to deal with. It is often difficult definitely 
to localize the pulsation within the tumor, and care must be taken not to 
mistake for tumor an aneurismal disturbance within the orbit accompanied 
by exophthalmos. A vascular pulsating tumor may be reduced in size, but 
not completely obliterated, by pressure and temporary obstruction of the cir¬ 
culation. An aneurism, by similar procedures, will suffer a much greater 
reduction in size. 

Innocence or Malignancy.—Of greatest importance to the patient is 
the question of malignancy. It is an accepted fact that, the more rapid 
the growth of a tumor, the more malignant it is. The clinical features 
of benign tumors are: they grow slowly; they are encapsulated, and because 
of this they are more or less mobile. They do not infiltrate, do not infect 


620 


MODERN OPHTHALMOLOGY. 


the lymph-glands, do not recur after complete removal, do not give rise to 
metastasis, and they endanger life only indirectly. On the other hand, 
malignant tumors grow rapidly; they have no limitation, but infiltrate sur¬ 
rounding tissues; and, because of this unbounded infiltration, infection 
takes place, which may be local or general. They are immobile independ¬ 
ently of the surrounding infiltrated tissues. They recur after removal, and 
inherently tend to destroy life. Metastasis belongs to malignant tumors, 
and shows the tumor to be no longer a purely local condition as it was at 
first, but that the disease has become general owing to infection. Sutton 
calls attention to the facts that innocent tumors are apt to be multiple; 
that sarcoma occurring in a paired organ is likely to arise concurrently in 
the fellow-organ; and that the occurrence of two primary carcinomata in 
the same individual is exceedingly rare. 

Symptoms.—The symptoms of orbital tumor are those due to pressure 
and destruction previously described. Pain may or may not be severe, 
depending upon the amount of pressure, direct or indirect, upon the sensory 
nerves. Diplopia is often the first indication of the growth, and should 
always be regarded with suspicion when its cause is not apparent. Late 
blindness is to be expected in probably the majority of orbital tumors. 
Early blindness is suggestive of primary involvement of the optic nerve or 
the parts around the optic foramen. 

Prognosis and Treatment.—From what has been said it will be seen 
that the diagnosis of an orbital tumor as to kind, location, and extent deter¬ 
mines the prognosis. The latter contemplates, first, the life of the patient; 
and, second, the preservation of vision. 

General surgical principles must be the guide for treatment. Com¬ 
plete removal by operation must, as a rule, be attempted where possible. 
Accepting the modern view that every primary malignant tumor is at first 
a purely local affection, the sooner removal is accomplished, the better. 
Furthermore, a benign tumor may destroy sight quite as readily as one 
which is malignant; it is well, therefore, to minimize by early operation 
the danger of irreparable damage from pressure. 

Senn places the average duration of life of persons suffering from 
malignant tumors of all kinds, without surgical interference, at about three 
years. Bearing this in mind, certain cases having also other inherently 
fatal diseases might advantageously be spared an operation. 

All tumors must be completely removed with a view to preventing a 
probable return. Bemoval of the tumor alone, when possible, will suffice 
for those which are benign. Malignant tumors are more safely removed 
with all of the orbital contents. The best results claimed by general sur¬ 
geons for operation for malignant tumors vary from 15 to 25 per cent, of 
permanent recoveries. 

Tumors situated deep in the orbit may sometimes be removed by an 
osteoplastic operation without undue destruction of the remaining orbital 
structures, after the method of Kronlein, which will be described later. 


DISEASES OF THE ORBIT. 


621 


Varieties of Tumors.—The individual tumors which are found in the 
orbit may be divided into (1) those composed of connective-tissue elements 
and (2) those composed of epithelial elements. The connective-tissue 
tumors are lipoma, chondroma, osteoma, sarcoma, neuroma, and angioma. 
The epithelial tumors are papilloma (cutaneous horns), adenoma, carci¬ 
noma (cancer), and squamous carcinoma (epithelioma). 

Lipoma.—The general characteristics of lipomata are that they are 
encapsulated, frequently lobulated, and sometimes congenital. They grow 
slowly and are benign. Billroth found that in a number of instances they 
are symmetrical, and like other benign tumors, as noted by Sutton, are 
multiple. Certain varieties (lipomata telangiectodes) are very vascular 
and some contain blood-channels (lipomata cavernosa). Although the orbit 
contains a large amount of fat, lipomata arising actually within the orbit 
are exceedingly rare. In considering lipoma it should be remembered that 
in Basedow s disease the orbital fatty tissue sometimes undergoes a general 
hypertrophy. Such an hypertrophy may also be secondary to an angioma, 
as was the condition in a case of angioma lipomatodes reported by Ivnapp. 

Angioma,—An angioma is a tumor composed entirely of newly formed 
blood-vessels. Dilations, enlargements, and communication of pre-exist¬ 
ing blood-vessels must be excluded, as are all aneurisms or varicose veins. 
Depending upon the character of blood-vessels of which they are composed, 
there are three varieties of angioma, viz.: capillary, cavernous, and 
plexiform. 

Capillary Angiomata, simple nevi, or mothers’ marks, are always con¬ 
genital, and show a predilection for the skin of the face around the orbit. 
They differ in color, depending upon whether the blood-vessels are super¬ 
ficially or deeply situated (Billroth). The consistence is determined b} ? the 
relative amount of connective tissue present. Those angiomata having but 
little connective tissue are soft and easily compressible, while those rich in 
connective tissue are quite firm and resistant. 

Cavernous Angiomata contain irregular communicating blood-spaces. 
They occur anywhere within the orbit, a favorite site being behind the eye¬ 
ball, .within the muscle-cone. They are larger and more dangerous than 
the capillary variety, and have a tendency to progress. They may be con¬ 
genital or may occur at any time during life. 

Plexiform Angiomata consist of a number of tortuous blood-vessels 
which are parallel one with another. They may be composed of arteries, 
veins, or both. Pulsation is generally present. If the tumor rests against 
the orbital wall, the underlying bone may be absorbed. 

Diagnosis. —All blood-tumors are more or less reducible upon pressure. 
Bruit and pulsation are generally present in cavernous and plexiform 
angiomata. These two varieties are also increased in size by all actions 
which tend to raise the blood-pressure, such as crying, laughing, straining, 
etc. The capillary angiomata around the orbit are generally found on the 
lids or near the orbital margin, and are readily recognized. The differential 


622 


MODERN OPHTHALMOLOGY. 



diagnosis between a true angioma and an aneurismal condition deep in the 
orbit may be impossible. 

Prognosis. —Angiomata, as a rule, are benign tumors. They may, 
however, be transformed into sarcomata of a most malignant type. They 
frequently enter into combination with other tumors, supplying the vascular 
elements and making the condition more serious than were either tumor 
alone present. Such combinations are angiolipoma, angiofibroma, angio- 
adenoma, angiosarcoma, and angiocarcinoma. They may occasionally dis- 


Fig. 361.—Fibrosarcoma of the orbit. (Wilson.) 

appear spontaneously after obliterative inflammation. On the other hand, 
inflammation of a cavernous or plexiform angioma may give rise to septic 
thrombophlebitis and death from pyemia. Pressure of an orbital angioma 
might, of course, readily destroy vision, and an erosion of bone might result 
from a pulsating tumor. 

Treatment. —If it can be done, excision is the treatment par excellence 
for angiomata. This, in deep-seated orbital angiomata, is often impossible 
without an amount of destruction which might be considered scarcely justi¬ 
fiable in dealing with a tumor the natural tendency of which is innocent. 







DISEASES OF THE ORBIT. 


G23 


Such means as will cause coagulation of the blood and obliteration of 
the tumor are to be considered. With these comes the great danger of 
septic thrombophlebitis. As coagulating injections should never be em¬ 
ployed without ligature, their use in the treatment of orbital angiomata is to 
be condemned. Repeated electrolysis is of value in the treatment of super¬ 
ficial angiomata, and might be successfully tried in certain of the more 
deeply situated ones. Ignipuncture, or puncture with a red-hot Paquelin 
cautery-needle, is excellent treatment for superficial angiomata which are 
readily accessible to the needle. 

Ligation of the arteries supplying the tumor, or of the main trunks 
going to the part of the body containing the tumor, has not proven satis¬ 
factory. The collateral circulation soon causes a return of the growth. In 



i 


Fig. 362.—Orbital tumor in a case of sarcomatosis. (W. T. Shoemaker.) 

I 

excising an angioma care should be taken not to cut into the tumor, as 
troublesome hemorrhage is apt to follow such a procedure. 

Lymphangioma is a tumor composed of lymphatic vessels. It is gen¬ 
erally congenital, and tends to grow after birth. It contains more con¬ 
nective tissue than does an angioma, and is consequently more firm. Clinic¬ 
ally it presents many of the characteristics of angioma. Its occurrence in 
the orbit is very rare. The prognosis is not favorable. 

Chondroma, or Enchondroma, is a tumor composed of hyalin cartilage. 
It is one of the most benign tumors, grows very slowly, and is so perfectly 
encapsulated that it is, as a rule, easily removed surgically. Its occurrence 
in the orbit is very rare, in which case it may be found in the orbital cellular 
tissue, or with greater frequency in the lacrimal gland. Clinically, it is 
hard and firm, and may be mistaken for osteoma. If, as enchondromata 
sometimes do, the tumor should undergo mucoid degeneration, a point of 


624 


MODERN OPHTHALMOLOGY. 


differential diagnosis between it and an osteoma would be the fluctuation in 
the degenerated mass. An enchondroma is usually unaccompanied by 
pain. It is a tumor of childhood or of early adult life. 

Sarcoma.—Several varieties of sarcoma may occupy the orbit, such as 
fibrosarcoma, myxosarcoma, cystosarcoma, osteosarcoma, cylindroma, plexi- 
form sarcoma, and melanosarcoma. The individual embryonal connective- 
tissue cells may be round or spindle shaped. Of all tumors occurring 
primarily in the orbit, sarcomata are the most frequent, the most malignant, 
and the most certain eventually to destroy life. Being without capsules, 
they rapidly infiltrate, and cause more or less immobility of the eyeball. 
They are of rajfid growth, often attaining great size, and give rise to pain. 
They are firm, rather uneven of surface, and with few exceptions they are 
free from pulsation and fluctuation. As a rule, the eyelids remain soft and 
free. They tend to invade any or all of the surrounding cavities. More 
often they are intra-orbital secondarily rather than primarily. A primary 
sarcoma of the chorioid frequently breaks through the sclera into the orbital 
cavity. Barely is the eyeball attacked secondarily by a sarcoma originating 
within the orbit proper. 

Although certain varieties of sarcomata are more rapidly destructive 
than others, notably the cylindroma and the melanotic variety, they are all 
sufficiently so to allow of no temporizing when once the diagnosis has been 
made, providing the case is seen early. The only possible chance of 
removal without recurrence is when the tumor might be said to be in its in- 
cipiency, or when, according to Senn, the tumor is a purely local affection. 
Bemoval after infection has taken place is followed by recurrence, which is 
generally more rapid and extensive than was the primary tumor. The 
tissue of origin has been found to be the orbital fat, the capsule of Tenon, 
the episcleral connective tissue, the periosteum of the orbital bones, the 
lacrimal gland, or the sheath of the optic nerve. Practically it makes little 
difference from what individual structure the tumor springs, as in all cases 
complete exenteration of the orbit is demanded. 

The microscope alone will determine definitely the variety of sarcoma 
with which we are dealing; and even this will often show combinations and 
arrangements quite atypical. The melanotic element of a sarcoma is, of 
course, readily determined. 

Osteosarcomata encroaching upon the orbit are, in the majority of cases, 
not limited to the orbital bones, but have originated elsewhere in the bones 
of the skull, and have an extensive distribution. 

Osteoma.—Such a tumor is defined by Sutton as an ossifying chon¬ 
droma. The term should be limited to a true tumor, and not used, as is 
often the case, to designate those conditions which, though clinically similar, 
are pathologically not true tumors. Exostoses due to the ossification of 
existing previously normal structures or to calcification of inflammatory 
products are histogenetically not tumors. Osteomata are of two kinds, and 
structurally resemble the shaft of the long bones and cancellous bone-tissue, 


DISEASES OF THE ORBIT. 


625 


respectively. They are thus compact or cancellous. They are essentially 
benign, but may cause death or less disastrous results mechanically, attain¬ 
ing eventually great size, though growing very slowly. Pain is a symptom 
only when they press upon sensory nerves. Compact osteomata are those 
found in the orbit. They show a preference for the frontal sinus and the 
roof of the orbit, but may occur in any portion of the orbital walls. If in 
the roof, the ej-eball is pushed downward. They are exceedingly dense, re¬ 
sembling ivory. Their removal from this situation must be undertaken with 
gieat care, as in the operation the anterior cerebral fossa may be easily 
opened, with serious consequences. Their removal is best accomplished by 
completely denuding the tumor of periosteum, then drilling through its base 
a number of holes, after which careful manipulation with mallet and chisel 
will, more or less perfectly, remove the growth. 

I he diagnostic points of osteomata are their extreme hardness, their 
manifest attachment to bone, perfect fixity, absence of pain in the tumor 
itself, and slowness of growth. Osteomata originating in the sphenoidal 
sinus tend to extend backward into the cranium. Some few cases of osteoma 
exfoliate spontaneously, leaving very extensive disfigurement. 

Plexiform Neuroma.—A plexiform neuroma is a benign tumor com¬ 
posed essentially of an overgrowth of the connective tissue of a nerve-sheath. 
More especially is the endoneurium involved. Thus the tumor lies along a 
nerve-trunk or in a plexus of nerves. It is of slow growth and painless. 
In the orbit it is rare, but few cases having been reported. In those the 
situation was in the upper, outer angle of the orbit, near the lacrimal gland, 
displacing the eyeball downward, inward, and forward. If it is an exten¬ 
sion from a tumor lying in the skin around the orbit, the diagnosis can be 
made with much greater certainty. It should be completely removed. 

Epithelial Tumors.—These are represented by three great classes, 
namely: papillomata, adenomata, and carcinomata. Within the orbit they 
do not primarily occur, except adenomata and carcinomata in connection 
with the lacrimal gland and the eyeball, and are therefore to be considered in 
the chapters dealing with these structures. Secondary invasion of the orbit 
by epithelial cancer originating in the skin of the lids, or in one of the 
adjacent cavities, is not infrequently met with. The destruction wrought is 
often very great, as in a case recently operated on in the German Hospital, in 
Philadelphia, in which after exenteration the floor, the roof, and the inner 
wall of the orbit were found to be destroyed. 

Cysts of the Orbit.—True cysts consist of an abnormal dilation of pre¬ 
existing cavities. Under this restricted definition we find in the orbit 

1. Cysts in connection with certain bursas situated around the superior 
oblique muscle, where its tendon passes through the trochlea, and also 
between the levator palpebras and superior rectus muscles. These cysts 
have been described as hygromatous degeneration of the orbital bursas— 
exudation cysts. 

2. The cystic condition sometimes found in connection with microph- 

40 


626 


MODERN OPHTHALMOLOGY. 


thalmos and anoplithalmos. Such cysts are situated in the lower lid and 
extend deep into the orbit. 

3. Eetention cysts, or some of those called by de Wecker follicular cysts, 
are thought by him to have their origin in the follicles of the skin. They 
may extend into the orbit. 

4. Cystic degenerations of the lacrimal gland, which are considered in 
the chapter treating of that organ. 

5. Extravasation cysts, which are often spoken of as hematoceles and 
hematomata,—blood-cysts,-—are exceedingly rare, if not of doubtful occur¬ 
rence in the sense of having a true cyst-wall and bloody contents. Dermoids 
are sometimes very vascular, and, according to Berlin, puncture for diagnos¬ 
tic purposes ma}^ cause hemorrhage within them. Such a condition might 
be mistaken for a blood-cyst, but the true character of the affection would 
remain the same. 

There are two cystic conditions found in the orbit of parasitic nature, 
namely: hydatid, due to the echinococcus, and the cysticercus cellulosce. 
These conditions do not fall within the above definition of true cysts. They 
occur wheresoever the parasites lodge, and make for themselves space by 
pushing aside tissue, and not by the dilation of pre-existing cavities. 

Dermoids are sufficiently distinctive in origin and history to be classed 
alone. Their presence in the orbit has been mentioned on page 619. 

All cysts and cystic conditions within the orbit are, per se, innocent. 
The one general characteristic symptom is fluctuation. Since this is com¬ 
mon to all cysts, it simply indicates the presence of contained fluid, and 
does not aid in a differential diagnosis as to the kind of cvst. It must not 
be forgotten that cystic degeneration may take place in malignant tumors, 
and might thus give rise to an error in prognosis. The other symptoms 
are those common to all growths within the orbit, but often with variations 
in degree. For instance, immobility of the eyeball in case of malignant 
orbital tumor often amounts to absolute fixity, whereas cysts generally cause 
only a restriction of movement. 

Exploratory puncture, bringing to examination the contents, is of 
great value in determining the nature of the cyst. The presence of scolices 
will show at once that we are dealing with the echinococcus. The aspira¬ 
tion of cerebro-spinal fluid requires a very careful and critical examination 
of the case before further procedure. The condition is either a meningo¬ 
cele or encephalocele, or an obliterated meningocele: i.e., one in which the 
neck of the sac has been constricted and obliterated, leaving the sac, with 
its cerebro-spinal fluid contents, in the orbit, but no longer connected with 
the brain. In the first instance non-interference is imperative; in the sec¬ 
ond removal may be attempted with impunity. 

Talko has reported a case of congenital cyst situated deep in the orbit 
of a 3-months-old child, pushing the eyeball forward. Operation was at¬ 
tempted and the anterior portion of the cyst was removed. Serous fluid 
escaped for ten days, when the child died. The finger could be pushed 


DISEASES OF THE ORBIT. 


627 


into the inferior orbital fissure and into the optic foramen. He believed 
that it was, beyond a doubt, a posterior meningocele. 

The diagnosis of the cysticercus is problematic until after removal. 
Ciliary neuralgia is said to be rather a constant symptom of echinococcic 
cyst. 

Treatment.— Orbital cysts may be treated by excision, incision, injec¬ 
tion, or electrolysis. Complete excision, when possible, is preferable. 
When this is not practical, incison, liberation of the cystic contents, and 
destruction of the sac, so far as possible, with the curette or by the 
injection of iodin should he tried. The writer has had no experience with 
electrolysis. 

INFLAMMATIONS OF THE ORBIT. 

Periostitis.—-Like the same process elsewhere, periostitis of the orbital 
bones may be acute or chronic, localized or diffused, and is characterized by 
deep-seated pain and swelling. Secondary to the swelling the neighboring 
intra-orbital structures may become involved. Thus swelling and edema 
of the lids and conjunctiva, limitations in the movements of the eyeball, and 
proptosis and other malpositions of the globe are produced. The patient 
may complain of diplopia. Pressure on the optic nerve may give rise to 
neuritis, demonstrable upon ophthalmoscopic examination, or atrophy of 
the nerve may be caused by direct pressure. 

Etiology.— Traumatism, rheumatism, syphilis, and scrofula are the 
potent etiologic factors, syphilis, either acquired or congenital, being the 
most frequent. 

Symptoms and Course.— Acute periostitis, if extensive, may be ush¬ 
ered in by a chill, followed by a rise of temperature. The patient will 
experience pain and distress, often severe in character, located in and 
around the orbit; and will frequently complain of frontal headache. If 
the inflammation is deeply seated, movements of the eyeball and pressure 
backward will cause pain within the orbit. If the orbital margin is affected, 
the overlying skin will be swollen, red, and adherent, the pain and tenderness 
on pressure being at times exquisite. The pain is generally worse at night. 

The course of the disease is that of any acute inflammation. It may 
terminate in resolution with complete and rapid recovery; or abscess for¬ 
mation may supervene with a variable collection of pus, undermining and 
detaching the periosteum and thus encroaching more upon the orbital 
space; or it may result in bone destruction (caries and necrosis), with the 
formation of sinuses and sequestra, which carry the disease into chro- 
nicity. Chronic periostitis may last for months or years, while intractable 
sinuses, retraction of the skin with alteration in shape and mobility of 
the eyelids, set up a train of symptoms which may continue long after the 
original disease has subsided. 

Caries generally attacks the margin of the orbit, and is most frequent 
in syphilitic and scrofulous children, whereas necrosis is most frequent in 


628 


MODERN OPHTHALMOLOGY. 


the adult and follows acute periostitis or traumatism, such as fracture de¬ 
nuding the bone of its periosteum. Large portions of bone may become 
exfoliated and great deformity may result. 

The location of orbital periostitis, whether marginal or deeply seated, 
is of great importance to the patient, the most dangerous points of attack 
being at the apex and at the roof. At the apex is the optic nerve, with its 
rather vulnerable sheath; pressure here may cause neuritis or rapid 
atrophy of the nerve. The extra-ocular muscles, with the exception of the 
inferior oblique, have their origins at this point, forming the apex of the 
muscle-cone, while beneath the external rectus muscle is the ciliary gan¬ 
glion. Therefore the pressure, if severe or long continued, may cause per¬ 
manent paralysis of one or more of these muscles. The roof of the orbit 
is thin and easily destroyed, in which event direct communication would 
be established with the anterior cerebral fossa. The danger of meningitis 
would then be imminent. Fortunately the most frequent situation of 
orbital periostitis is near the margin, up and out. 

Diagnosis. —This is generally not difficult; the boring, deep-seated 
pain, with nocturnal exacerbations, together with the external signs, serve to 
implicate the periosteum in the inflammatory process. To determine, how¬ 
ever, to what extent other structures are involved; or, if there be, for 
example, tenonitis, cellulitis, or orbital phlegmon, which structure is pri¬ 
marily affected may be difficult or uncertain. Tapping with the finger 
around the orbital margin, so as not to disturb the orbital contents, will 
often serve to locate the affection in the bones. If this can be done without 
pain, the bone or periosteum is probably not involved. Vice versa, if gently 
pushing back the eyeball, with just sufficient force to reach the soft parts 
only, causes marked pain, we probably have to deal with tenonitis or cellu¬ 
litis. 

Syphilitic periostitis is generally a tertiary manifestation, but it should 
be remembered that it may also be found in the complex of secondaries. 
Noyes has noted the fact that immobility of the eyeball due to periostitis is 
to be differentiated from ophthalmoplegia of third-nerve origin by the 
absence of ptosis. The third nerve divides at its entrance into the orbit 
into an upper and a lower portion. The upper division supplies the levator 
muscle, and has a well-protected course between that muscle and the superior 
rectus, entering the lower surface of the muscle. 

If sinuses be present, evidencing necrosis or caries, great care and gen¬ 
tleness must be used in probing lest the bone be further injured. Espe¬ 
cially easy is it to perforate the necrotic bone at the roof of the orbit and 
pass the probe into the cranial cavity, often with serious results. 

Prognosis. —The prognosis of acute orbital periostitis is favorable, 
providing the process can be checked before irreparable damage has been 
done to the intra-orbital contents. Chronic periostitis may last for months 
and years with the formation of intractable sinuses and occasional exfolia¬ 
tion of bone, or with established communication with the adjacent cavities. 


DISEASES OF THE ORBIT. 


629 


Gummata occasionally attack the periosteum of the orbital bones, 
though they occur much less frequently here than in the other cranial 
hones. The condition is a rarefying osteitis: i.e., the subperiosteal bone- 
cells undergo softening and become in structure similar to the gummatous 
tissue. The symptoms are those of ordinary periostitis with certain exag¬ 
gerations. Nocturnal pain and neuralgia are prominent symptoms. The 
swelling is more circumscribed than in periostitis and simulates more a 
true tumor, exophthalmos being frequently produced if the gumma is in 
the deeper parts of the orbit. Orbital gummata cause great immobility of 
the eyeball, marked fixity of the eyeball being characteristic of this form 
of inflammation. They are amenable to specific treatment, but when they 
disappear great holes and depressions are left in the bones. 

Treatment. —Orbital periostitis requires constitutional and local reme¬ 
dies. Constitutionally the treatment depends upon the cause, if known, and 
in any event the general nutrition of the patient is of importance. The 
first stages of the attack, if marked, must be met with depletion and anti- 
phlogistics. A purge, preferably salts, should be given, followed by a fever 
mixture, if fever be present. If the presence of syphilis is confirmed, mer¬ 
cury and potassium iodid are indicated. If of rheumatic origin, salicy¬ 
late of sodium and the iodid are indicated. If the patient is scrofulous, 
iron, codliver-oil, hypophosphites, and appropriate diet are to be considered. 
For the control of pain salicylate of sodium given in full doses will seldom 
fail. It is especially useful in aborting or annulling the nocturnal 
paroxyms. 

Locally, the indications are to limit the exudation and promote ab¬ 
sorption and resolution. Although the application of cold is generally of 
use in the first stages of inflammation, practically it is not to be recom¬ 
mended in periostitis, heat being much more efficient as well as more grate¬ 
ful to the patient. Hot fomentations therefore play an important role. 
They must, however, be properly applied, the object being to maintain a 
uniformly high degree of temperature. Hot compresses replaced every half¬ 
minute for thirty minutes, repeated in an hour or two, will generally yield 
good results. A lukewarm or cold compress placed over the part for an 
indefinite time is useless. 

If pus is present it must be liberated. This is to be done by passing 
a long bistoury in such a way as to avoid the eyeball, the optic nerve, and 
the ciliary ganglion. The incision should be made through the periosteum 
to the bone, and the mouth of the opening should be kept patulous with 
gauze packing. Sinuses should be carefully syringed, and any loose piece of 
bone presenting should be removed. It is well to form a definite idea of the 
size and extent of the loose bone before attempting its removal, always 
bearing in mind the proximity of the cranial cavity, the frontal and eth¬ 
moidal sinuses, and the antrum. 

Periostosis is a thickening of the periosteum following inflammation. 
It is said to occur in those cases in which the bone proper has not been 


630 


MODERN OPHTHALMOLOGY. 


sufficiently diseased to induce caries. It more frequently affects the mar¬ 
gin, and is generally syphilitic in origin. It may attack the periosteum 
at the apex, in which case permanent, but slowly produced, paralyses of the 
ocular muscles, or even atrophy of the optic nerve, may result. At the 
orbital margin neuralgia from pressure of the supra-orbital or infra-orbital 
nerves is a frequent symptom. The treatment is antisyphilitic aud ab¬ 
sorbent, mercury and potassium iodid yielding the best results. 

Hyperostosis of the orbital bones is an exceedingly rare condition, hav¬ 
ing been noted by Bull but four times in about twenty thousand cases. It 
is characterized by an increase in the diameter of the bone, and is primarily 
a disease of the bone itself. Such a. condition could, of course, cause marked 
and curious deformity. Syphilis is not thought to play much of a part in 
the causation. 

Exostosis is usually due to syphilis, and may occur in any portion of 
the orbital wall. It is often caused by a long-continued chronic periostitis. 
Exostoses may grow into the orbital cavity and produce pressure symptoms. 
They grow more frequently, perhaps, from the os planum of the ethmoid 
than from other areas. They are of more abrupt elevation than the swell¬ 
ings of periostosis, and partake more of the nature of a tumor with better- 
defined limitations. They will sometimes yield to antisyphilitic treatment. 
If they do not yield to such treatment, but become destructive in their 
progress, they must be surgically removed. They should be attacked at the 
base with chisel and mallet. The chiseling must be done very carefiilly so 
as to not fracture the bone. It is best to use the corner of the edge of the 
instrument, progressing slowly, with repeated short strokes. 

Orbital Cellulitis and Phlegmon.—Orbital cellulitis, or inflammation 
of the fatty cellular tissues within the orbit, may occur as an acute, as a 
subacute, or as a chronic inflammation. All grades of severity are recog¬ 
nized, from the mildest, with only local symptoms and a course tending 
toward rapid resolution and recovery, to the phlegmonous variety w'ith 
grave constitutional disturbance, thrombosis of the cavernous sinus, and 
extension to the brain, the latter causing purulent meningitis and death. 

It may follow traumatism, such as-a blow, punctured wounds, or frac¬ 
ture of the orbital bones, or it may be an extension from local pyogenic 
processes in neighboring parts. It has been seen after laceration of the 
scalp caused by unskillful use of the obstetric forceps. Long exposure to 
cold is sometimes a cause. 

Among other causes of this condition are periostitis; meningitis 
complicated by thrombosis of the cavernous sinus and ophthalmic vein; 
panophthalmitis, in which the process passes beyond Tenon’s capsule; sup¬ 
puration in the ethmoidal cells or around the upper teeth and upper jaw; 
and very rarely dacryoadenitis. Typhoid and typhus fevers, scarlatina, 
pyemia, and puerperal septicemia, and especially facial erysipelas may all 
cause orbital cellulitis. When it occurs in the course of these diseases it 
must be regarded as a very serious and often dangerous complication. 


DISEASES OF THE ORBIT. 


631 


Symptoms. —The symptoms, in mild cases, are dull pain and headache; 
restricted ocular movements, with perhaps slight proptosis and diplopia; 
swelling of the lids, and edema of the conjunctiva (chemosis). In the 
phlegmonous form there is an exaggeration of these symptoms together with 
constitutional disturbance and other symptoms due to pressure. 

The attacks may commence with a chill followed by a fever. The lids 
are greatly swollen, tense, and dusky, all the folds and landmarks being 
obliterated. The eyeball is pushed far forward, and is absolutely fixed. 
The chemosis is often so extensive as to hide completely the cornea, which 



Fig. 363.—Abscess of tbe orbit in a child ten days old, injured* during 
instrumental delivery. (Author.) 

may become devitalized and slough. Pressure on the optic nerve will cause 
neuritis and atrophy. Such a condition of congestion and stagnation is 
generally attended by more or less thrombosis of the veins which may con¬ 
tinue into the cavernous sinus, and in some cases may extend to the sinus 
of the other side, and thus affect secondarily the fellow-eye. If allowed 
to run its course, pointing finally takes place, followed by rupture and the 
liberation of pus. The point of rupture is usually through the upper lid 
near the orbital margin. 

Prognosis. —The milder cases are amenable to treatment, and the prog¬ 
nosis is good, complete recovery being the usual termination. In graver 





G32 


MODERN OPHTHALMOLOGY. 


cases the prognosis as regards the life of the patient is favorable. Should 
meningitis occur, a fatal termination is to be expected. As regards the 
future usefulness of the eye, prognosis is to be based upon the amount and 
duration of pressure and the extent to which the eyeball has taken part in 
the inflammation. Sloughing of the cornea, optic-nerve atrophy, throm¬ 
bosis in the retinal veins, and a development of pus within the eyeball are all 
fatal to vision. 

Treatment.— This should be along the lines of general surgery. The 
patient should be sent to bed. To limit exudation cold is indicated in the 
earliest stages. To aid absorption and resolution heat should be applied 
thereafter. Hot stupes give great relief and are much to be depended upon. 
Depletion by the application of leeches to the temple is often of service in 
the commencement of the attack. Pus must be liberated at once, for it 
can work its way backward, with disastrous results. As it is generally pres¬ 
ent long before it manifests itself by pointing, when the symptoms are 
severe, its presence should be presumed, and free incisions should be made 
deep into the orbit under strict antiseptic precautions. Even though no 
pus be found, the local bloodletting will fulfill an important indication. 
The incision should be made with a long, straight bistoury—by preference, 
through the conjunctiva. If, on account of swelling and edema, this should 
be impracticable, the incision can be made through the upper lid. The 
knife should pass close to and parallel with the orbital wall, avoiding the 
eyeball and the optic nerve. The opening of the incision should be freely 
enlarged, a bichlorid-of-mercury solution (1 to 3000) should be carefully 
introduced by syringing, and drainage should be maintained by loose 
packing. The general treatment is tonic and supportive. Good diet, iron, 
quinin, strychnin, and alcohol in the form of milk punches are indicated. 

Inflammation of the Oculo-orbital Fascia (Tenonitis).—Inflammation 
of Tenon’s capsule is sometimes found as a distinct affection and always is 
a part of severe orbital cellulitis, in which case, however, it is scarcely to be 
differentiated from the more general inflammatory process. 

Symptoms. —The symptoms include slight or moderate swelling and 
edema of the upper lid, which, on account of the firm attachment of proc¬ 
esses of the orbital fascia to the upper margin of the tarsus, may be more 
marked in the lid above the tarsus. Chemosis, pain on motion, and re¬ 
stricted movement of the eyeball, with some proptosis, are present. These 
symptoms are all found in orbital cellulitis, in which condition they are 
generally more pronounced. The most characteristic symptom of tenonitis, 
and the one which, when present, establishes the diagnosis, is the occurrence 
of vesicular swelling over the insertion of one of the straight muscles. It 
will be remembered that the straight muscles pierce Tenon’s capsule by a 
kind of invagination, thus offering a favorable situation for the pushing 
forward of serous fluid collecting within Tenon’s space. 

Etiology. —Tenonitis may follow operations directly disturbing the 
capsule, such as tenotomies and advancements. It is then usually severe and, 


DISEASES OF THE ORBIT. 


633 


if suppurative, endangers the integrity of the e} r eball. Bull mentions a case 
known to him of double panophthalmitis resulting in blindness from a 
simultaneous tenotomy of both internal recti muscles. Such a calamity 
sounds a note of warning against the slightest carelessness in the perform¬ 
ance of these operations, however simple and usually free from danger they 
seem to be. Zentmayer reports tenonitis as a complication in a case of 
typhoid fever. It has been known to occur after diphtheria and influenza. 
The most frequent causes of idiopathic tenonitis are rheumatism and gout. 
These diseases are often responsible for episcleritis, with which certain cases 
of tenonitis might be confounded. Ordinary care in the examination 
should make the differential diagnosis clear. 

Prognosis of the traumatic cases must be guarded, the danger of 
panophthalmitis being imminent in any pyogenic inflammation of the cap¬ 
sule. The other cases, as a rule, recover, leaving the parts functionally 
normal. The duration depends upon the character of the inflammation, 
and in chronic cases may be many months. 

Treatment.- This does not differ from that of the preceding affection. 
If pus is present, free incision into the capsule for its exit must at once be 
made. This is an important procedure, and must be unhesitatingly accom¬ 
plished. Salicylic acid, or salicylate of sodium, potassium iodid, or col- 
chicum is indicated if the cause is rheumatism or gout. 

Diseases of the Frontal, Ethmoidal, Maxillary, and Sphenoidal Sinuses. 

These cavities or air-spaces are lined with mucous membrane, and are 
liable to inflammation by extension from the nasal mucous membrane or to 
retention disturbances due to occlusion of their natural outlets. The two 
frontal sinuses are usually completely separated from each other by a thin 
bony partition. They are not developed until about the sixth or seventh 
year, and vary greatly in size in different individuals. Tilley, after an 
examination of one hundred and twenty skulls, concludes that the normal 
frontal sinus should measure twenty-eight millimetres from the median line 
outward, and twenty to twenty-eight millimetres in its vertical dimension. 
Some sinuses he found only large enough to contain an ordinary bean,while 
others had a capacity ten times as great. The frontal sinuses communicate 
with the anterior ethmoidal cells, and in common with them with the nasal 
cavity at the middle meatus, through the infundibulum. The anterior and 
posterior ethmoidal cells do not communicate with each other, being sepa¬ 
rated by a bony partition. The posterior ethmoidal cells are sometimes in 
communication with the sphenoidal sinuses. They open into the superior 
meatus of the nose. 

The maxillary sinus, situated in the body of the superior maxilla, com¬ 
municates with the middle meatus of the nose. Its roof is the thin orbital 
plate of the superior maxilla, forming the floor of the orbit. In some cases 
the roots of the first and second molar teeth perforate the floor of the 
antrum. The floor of the antrum may be in relation with all the teeth of 
the true maxilla from the canine to the wisdom-tooth (Sattler). 


634 


MODERN OPHTHALMOLOGY. 


The sphenoidal sinuses do not exist in early childhood. When de¬ 
veloped they are very irregular in size and in shape. They communicate 
with the superior meatus of the nose, and, as mentioned above, occasionally 
with the posterior ethmoidal cells. 

Inflammation in these sinuses generally starts from the nose, a catarrhal 
rhinitis, for example, extending through the infundibulum to the frontal 
sinuses and to the anterior ethmoidal cells, or from the superior meatus into 
the posterior ethmoidal cells and sphenoidal sinuses, or from the middle 
meatus into the antrum. The antrum may also become infected through 
the teeth, which in many cases perforate its floor. 

The first stage is a thickening and congestion of the mucous membrane, 
a narrowing of the natural outlet, and a retention of mucous secretion 
within the sinus. This condition is known as mucocele of the sinus. Fol¬ 
lowing this there may be great distension of the cavity; the orbital space is 
encroached upon, and ocular symptoms make their appearance. The final 
stage is that of suppuration. The process remains no longer limited to the 
sinus; orbital abscess may ensue, with all its dangers, or extension back¬ 
ward or upward into the brain-cavity may cause a fatal meningitis. 

Without prompt and skillful treatment necrosis of the bones and the 
formation of intractable fistulas may generally be expected in these cases. 

Tumors and polypi may spring from the mucous membrane of the 
accessory sinuses and push their way into the orbit, or the sinuses may be¬ 
come secondarily invaded by tumors originating elsewhere. 

Symptoms and Diagnosis. —There are certain symptoms of the dis¬ 
eases of the accessory sinuses in their relation to the orbit which are common 
to all the cavities. The first stage of the disease is marked by pain on 
pressure or percussion over the affected sinus. If this is the frontal sinus, 
headache above the root of the nose is an almost constant symptom. There 
may be neuralgic pain over the course of the supra-orbital nerve and a dis¬ 
charge of mucus from the corresponding nostril. 

In ethmoiditis headache is less constant, and mucous discharge from 
the nostril perhaps is more constant. The pain in antral disease is located 
in the upper jaw, and sometimes over the course of the infra-orbital nerve. 

It is impossible to diagnose disease of the sphenoidal sinuses in the 
first stages. If pus has formed, its presence in the superior meatus of the 
nose is of diagnostic value. 

In the second stage, or that of distension, the diagnosis is easier. Dis¬ 
tension of the frontal sinus generally manifests itself at the upper, inner 
angle of the orbit. There is a rounded swelling between the trochlearis 
pulley and the angle of the orbit, pushing the eyeball downward and out¬ 
ward. Distension of the ethmoidal sinuses causes exophthalmos and a dis¬ 
placement of the eyeball outward. If the antrum become distended, the 
swelling generally presents in the floor of the orbit directly back of the 
orbital margin, giving rise to exophthalmos, with upward displacement of 
the eyeball. From the situation of the sphenoidal sinuses, as might be sup- 


DISEASES OF THE ORBIT. 


635 


posed, their distension may cause sudden blindness from pressure on the 
optic nerve. The exophthalmos would be directly forward. 

Of late the means for transillumination have been greatly improved, 
making it possible in many cases to determine with facility the presence of 
collections within the sinuses. They may all be transilluminated except 
the sphenoidal. 

The third stage of empyema, unless free drainage is obtained, is likely 
to be complicated by orbital abscess, the symptoms of which have been 
described. As the bones become thin from distension, fluctuation may often 
be elicited, thus distinguishing the condition from solid tumor. 

Among the reflex symptoms which may exist in disease of any of the 
sinuses are lacrimation, photophobia, reduced vision, restricted fields for 
form and color, and relative scotomata. Diplopia is present in accordance 
with the displacement of the eyeball. Muscle paralysis and optic neuritis 
will correspond to the amount and position of the pressure. 

Etiology.— The majority of cases have their origin in the nasal cavity. 
Such an inflammation may occur in erysipelas, epidemic influenza, typhoid 
and other infectious fevers, tuberculosis, or syphilis. Fracture of the 
bones may so alter the anatomy as to cause obstruction of the infundibulum, 
damming back the mucous secretion in the frontal sinuses and the eth¬ 
moidal cells. Disease of the teeth in relation with the maxillary sinus 
may be the exciting cause of antral disease. 

Treatment. —In the early stages this belongs to the rhinologist. In 
many cases the swollen mucous membrane at the openings of these sinuses 
into the nose may be effectually treated with adrenal solution, or other drugs 
with similar action, and the normal outlets thus can be kept open. In the 
later stages, on account of the ocular symptoms, these patients are gener¬ 
ally brought to the ophthalmologist. The indications are, first, to estab¬ 
lish a free communication with the cavity, and, second, through this com¬ 
munication to maintain drainage and cleanliness. In the case of the frontal 
sinus an opening is to be made with a stout knife through the thin and dis¬ 
tended bone at the upper, inner angle of the orbit. Then, with the finger 
in the sinus and a gouge up the nose, a second opening may be forced. A 
fenestrated drainage tube is then to lie passed from the sinus into the nose, 
through which careful and repeated syringing of antiseptic solutions may 
be carried on. 

In ethmoiditis the incision is to be made through the os planum of the 
ethmoid, and a passage for a drainage tube is to be forced into the nose. 

The antrum may be reached through the canine fossa of the malar 
bone or through the socket of the second molar tooth. If the floor of the 
orbit is thin and bulging, an opening may be made here, taking care not 
to injure the infra-orbital nerve. Much time is required for the treatment 
of these cases. It will often be necessary for the patient to wear a drain¬ 
age tube and to submit to syringing of the cavity several times daily for 
weeks or months. 


636 


MODERN OPHTHALMOLOGY. 


Cavernous-Sinus Thrombosis.—Thrombosis of the cavernous sinus as 
a primary affection rarely occurs. When present, it is usually the result 
of extension of a thrombotic process in the orbital veins, or a similar condi¬ 
tion in the other sinuses. 

Symptoms. —Whether marasmic or inflammatory (septic), the local 
symptoms are the same and are, first, those of venous stasis; second, those 
of pressure; third, those of paralysis: 

Individually considered they are edema of the lids, which may extend 
for some distance into the integument of the face; chemosis; and exoph¬ 
thalmos, which, at first slight, generally becomes pronounced. The eyeball 
is more or less mechanically restricted in its movements, and if the upper 
lid does not from edema obstruct vision on that side, diplopia is complained 
of. Interference with the cranial nerves running to the orbit is likely to 
occur. The third, the fourth, the ophthalmic division of the fifth, and the 
sixth nerves all traverse the cavernous sinus, and are liable to injury. The 
one most commonly affected is the third. We would then have divergent 
strabismus, stabile mydriasis, and ptosis. Paralytic ptosis, although a 
rather constant symptom, is often difficult to establish, on account of the 
mechanical ptosis due to edema of the lid. Other varieties of strabismus 
would, of course, occur were one or more of the other nerves paralyzed. 
At the commencement of the attack irritation preceding the paralysis would 
cause miosis. This, however, is of short duration. As in all conditions of 
retrobulbar pressure, the optic nerve may suffer neuritis or atrophy. 
Through the medium of the circular sinus the process may extend to the 
opposite side. According to Macewen, this occurs in more than half the 
cases. Such a transference is pathognomonic, and serves to diagnose posi¬ 
tively cavernous-sinus disease from intra-orbital disease with many symp¬ 
toms in common. Another important diagnostic sign of cavernous-sinus 
thrombosis, when present, is edema over the mastoid region. Its opcurrence 
has been explained as being due to stasis in the emissary vein of Santorini, 
which empties into the lateral sinus, which, in turn, directly communicates 
with the cavernous sinus. 

Owing to the free anastomosis of the orbital veins with the veins of the 
face, blood from the orbit has an extra- as well as an intra- cranial means of 
exit. To this arrangement is due the fact that certain cases of cavernous- 
sinus thrombosis will present orbital symptoms not commensurate with the 
amount of obstruction in the sinus. Such cases are of more gradual devel¬ 
opment, and favor the presumption that in them the process is extending 
from within outward, rather than from without inward, thus giving more 
time for the formation of an adequate collateral circulation. 

Thrombosis of the ophthalmic vein or of the cavernous sinus is accom¬ 
panied by pain, notably over the course of the supra-orbital vein and in the 
eyeball. The patient complains of varying degrees of headache, and, if the 
case is complicated with meningitis or brain-softening, cerebral symptoms 
are apparent. 


DISEASES OF THE ORBIT. 


C37 


Etiology.— Two forms of thrombosis are recognized—marasmic and 
inflammatory. The first is due to an impoverished condition of the blood 
and occurs usually at the extremes of life or as a complication of the exan¬ 
themata and other diseases producing marked debility. Inflammatory or 
septic thrombosis is caused by an alteration in the vessel-wall (phlebitis, 
meningitis), metastatic transference of inflammatory or septic products, or 
traumatism. Orbital cellulitis is almost invariably accompanied by more 
01 less thrombosis, which may readily extend into the cavernous sinus. 
Caries and necrosis of the bones of the skull or around the teeth have been 
responsible for some cases. Fracture of the skull—especially at the base, 
chronic otitis media, erysipelas, furunculosis, or pyogenic foci so situated 
as mechanically to infect the blood en route through the orbit and cavernous 
sinus are all recognized causes. 



Fig. 364.—Thrombosis of the cavernous sinus. (W. T. Shoemaker.) 

Prognosis.— The disease may last from a few days to several months. 
According to Macewen, the great majority of cases of cavernous-sinus 
thrombosis end fatally. This author further says that absolutely all cases 
of infective thrombosis end in death. 

Treatment.— This must follow general surgical principles, meeting 
exigencies as they arise. Hartley opened by trephine the cavernous sinus in 
a case diagnosed by Knapp, and removed the thrombus. This operation 
has been performed several times since. 

Hemorrhage into the Orbit.—In the vast majority of cases hemorrhage 
into the orbital cellular tissue is caused by traumatism, either direct or 
indirect. Instruments or foreign bodies thrust into the orbit must neces¬ 
sarily cause bleeding. Blows upon the eyeballs or head or fracture of the 
skull involving the orbital bones may permit of an outpouring of blood 


638 


MODERN OPHTHALMOLOGY. 


into the cellular tissue. The condition rarely occurs spontaneously, and 
may then be clue to hemophilia, scurvy, deterioration of the blood-vessels, or 
to too great a rise of blood-pressure incident to coughing, sneezing, strain¬ 
ing, etc. Once liberated within the orbit, the course of the blood is deter¬ 
mined by the layers and processes of the orbital fascia. It extravasates in 
the direction of least resistance, which is generally forward, and in a short 
time comes to view under the conjunctiva of the eyeball or eyelids. Ac¬ 
cording to the amount of hemorrhage the symptoms will vary from those 
scarcely noticeable to marked proptosis, limited ocular movements, great 
subconjunctival accumulation of blood, and pressure injury to muscles and 
nerves, including the optic nerve, with perhaps loss of vision. 

The diagnostic value of subconjunctival hemorrhage after injury, in 
determining fracture at the base of the skull implicating the orbital bones, 
has depreciated somewhat since the demonstration a number of times by 
autopsy of traumatic orbital hemorrhage without fracture. Evidence of 
orbital hemorrhage is, notwithstanding, a valuable and serious symptom 
after head-injury, and makes basal fracture at least probable. Sometimes 
the blood escapes into the nose, indicating fracture of the ethmoid bone. 

A few cases of spontaneous subperiosteal orbital hemorrhage in infants 
suffering from malnutrition have been reported by Spicer, and a so-called 
traumatic subperiosteal blood-cyst has been observed by Baquis, which 
disappeared within four days. Denig reports a case of subperiosteal blood- 
cyst situated behind the lacrimal gland, extending toward the orbital roof, 
where it had caused perforation into the anterior cerebral fossa. The pa¬ 
tient had received a severe orbital injury ten years before. 

Prognosis.— Insomuch as the optic nerve is always jeopardized by 
orbital hemorrhage if extensive enough to cause considerable pressure, the 
prognosis should be guarded quoad visas in the presence of pressure symp¬ 
toms. 

Treatment. —Absorption takes place in from three to six weeks and 
may be aided by hot fomentations. A pressure bandage may be indicated in 
certain cases, and, when the proptosis is so extensive as to prevent closure 
of the lids, the cornea must be carefully guarded. The use of the bistoury 
for the purpose of liberating the blood may be advisable when the bleed¬ 
ing has been excessive, but in ordinary cases it seems to the writer to be of 
doubtful efficacy, as extravasations are not often relieved by incisions. 

Pulsating Exophthalmos.—In typical cases this condition is character¬ 
ized by protrusion of the eyeball; noises or bruit to be heard at the entrance 
of -the orbit, or by auscultation over various points of the skull, even over 
the occiput; and by pulsation near the orbital apex transmitted through 
the eyeball. The exophthalmos, if unilateral, or if more pronounced on 
one side than on the other, gives rise to diplopia. The hruit is both a 
subjective and an objective symptom. It is increased by lying down or v 
stooping, or by any exertion raising the blood-pressure. The noises in the 
head are incessant and cause much distress. They stop or are greatly 


DISEASES OF THE ORBIT. 


639 


modified when the blood-supply to the side of the head affected is inter¬ 
rupted by compression of the common carotid artery. The pulsation—- 
generally demonstrable by careful palpation-—is sometimes visible. The 
veins of the lids, of the conjunctiva, and of the retina are often distended 
and tortuous—the result of passive hyperemia. In a certain number of 
cases optic neuritis, optic-nerve atrophy, retinal hemorrhages, glaucoma, 
and cataract have been noted. More frequent than these last-named 
symptoms is paralysis of the abducens nerve. 

Etiology. —Exophthalmos with pulsation may be due to a variety of 
lesions, both intra-orbital and extra-orbital. Thus, it may be a symptom 
of extremely vascular tumors within the orbit, due to a true aneurism of the 
ophthalmic artery in its intra-orbital or intracranial portion, aneurism of 
the internal carotid artery, arterio-venous communication, varicose dilation 
of the orbital veins, or communication between the internal carotid artery 
and the cavernous sinus. The last-named condition has been found to be 
the most frequent cause. Thus, the disease in the majority of cases is of 
intracranial origin, the protrusion of the eyeball and the other orbital 
symptoms being secondary and dependent upon venous obstruction. Riv- 
ington demonstrated the intracranial origin of pulsating exophthalmos, 
which was a distinct advance in the pathology of this condition. In an 
analysis of 19 autopsies Frost found orbital aneurism in 3, affection of the 
cavernous sinus in 2, aneurism of the intra-orbital portion of the ophthalmic 
artery in 2, arterio-venous communication in 8, and the condition unde¬ 
termined in 4. 

With arterio-venous or arterio-sinus communication we have obstruc¬ 
tion of the venous outflow of blood, which induces marked distension and 
varicosity of the veins. The blood-current then becomes reyersed, and the 
distended veins carry arterial blood (Sattler). At this stage pulsation 
commences. As more or less time is required for these changes to take 
place, and as, indeed, they may not take place, pulsation may not appear 
early nor need it occur at all. Bilateral pulsating exophthalmos of traumatic 
origin is to be explained by a transference of the obstructing process from 
the cavernous sinus of one side by way of the transverse and circular sinuses 
to the cavernous sinus of the opposite side. 

The majority of cases are traumatic; according to de Schweinitz, 60 
per cent.—110 in 181 cases. Punctured wounds, gunshot injuries, and 
fracture at the base of the skull are the chief traumatisms. Rupture of the 
internal carotid artery into the cavernous sinus is generally due to basal 
fracture. Other cases are idiopathic. 

Diagnosis. —The diagnosis in typical cases is not difficult, but the 
exact character of the lesion is often impossible to determine. Vascular 
tumors offer more resistance to pressure than do aneurismal conditions, and 
the proptosis caused is less likely to be directly forward. History of a fall 
or blow on the head with unconsciousness places the lesion probably 
with the majority: i.e., intracranial. Following penetrating wounds into 


640 


MODERN OPHTHALMOLOGY. 


the orbit, intra-orbital arterio-venous communication has likely been estab¬ 
lished. Whether the ophthalmic artery is the seat of an aneurism in its 
intracranial or in its intra-orbital portion is impossible definitely to deter¬ 
mine. 

Prognosis. —This is favorable, providing surgical interference is per¬ 
mitted. The distressing subjective symptoms can generally be relieved or 
completely cured. If the condition is allowed to continue and increase in 
severity, the eyeball is apt to suffer destruction from secondary glaucoma, 
or keratitis occurs from pressure on the ophthalmic division of the fifth 
nerve in its course through the sphenoidal fissure. 

Treatment. —The most rational and the most radical treatment, and 
that which promises the best results, is ligation of the common carotid 
artery. The operation is, however, not unattended by danger to life, al¬ 
though the danger is being minimized by modern surgical methods. De 
Schweinitz has tabulated one hundred and two cases in which the common 
carotid artery was tied, with a death-rate of 10.7 per cent. This mortality- 
rate in comparison with that given by some modern surgeons is extremely 
low. Digital compression has cured some cases, and probably should be 
tried first. With compression, full doses of potassium iodid and a re¬ 
stricted diet have been recommended. Spontaneous cure rarely occurs. 

De Schweinitz advises the order of procedure as follows: Compression 
with or without the administration of potassium iodid; in event of failure, 
ligation of the common carotid. He strongly recommends the early con¬ 
sideration of ligation in the treatment of these cases, believing that com¬ 
pression or medicinal treatment should be regarded as inefficient unless 
signs of amelioration promptly appear. 

Intermittent Exophthalmos is a rare condition in which the eyeball is 
protruded when the subject stoops or leans forward, and recedes within the 
orbit when he is erect or in the recumbent position. Or the exophthalmos 
may be voluntarily produced by the act of blowing. Posey reports a case 
in which a young adult could in this manner voluntarily proptose the left 
eyeball fifteen millimetres in advance of its fellow. The cause is presum¬ 
ably some varicose condition of the veins of the orbit. 

Enophthalmos.—This condition is a recession of the eyeball within the 
orbit, and may be idiopathic or traumatic. Idiopathically it is found after 
absorption of the orbital fatty cellular tissue in the aged, or after long- 
continued wasting disease, or after rapid extraction of the fluids of the body, 
such as occurs in Asiatic cholera (von Graefe). These cases are always 
bilateral. To a slight extent it may often be noted during an attack of 
migraine; it is then unilateral. Very rarely the eyeball is retracted by the 
combined and simultaneous action of the four recti muscles —spastic enoph¬ 
thalmos. W. Porster has recently reported a case of enophthalmos inci¬ 
dent to forcible separation of the eyelids, the eyeball returning to its normal 
position when no force was applied. The patient was aged and emaciated. 
Two similar cases have since been reported. 


DISEASES OF THE ORBIT. 


6-11 


Etiology and Pathology. —The pathology of traumatic enophthal- 
mos has been the subject of much discussion, and as yet is based on a num¬ 
ber of theories. Beer believes the lesion to be one of the nerve-centres or 
tracts, particularly of the sympathetic or trigeminal nerves, causing absorp¬ 
tion and atrophy of the orbital cellular tissue. Gessner presumes it to be 
due to periostitis of some portion of the orbital wall and inflammation of 
the retrobulbar tissue resulting in cicatricial contraction, the eyeball falling 
backward owing to the reduced bulk of the orbital contents. Schapringer’s 
theory is that Muller’s orbital muscle is paralyzed from injury to the sym¬ 
pathetic nerve, thus increasing the orbital space and permitting of recession 
of the eyeball. Lang, Tweedy, Langenbeck, and others regard fracture of 
the orbital wall as the determining cause of traumatic enophthalmos. In 
this connection a distinction should be made between displacement of the 
eyeball in certain cases of undoubted and extensive fracture and cases of 
enophthalmos in which no such fracture is demonstrable. Lederer con¬ 
cludes that traumatic enophthalmos is to be explained by fracture of the 
orbital wall and hemorrhage. The writer is of the opinion that the orbital 
fascia and Tenon’s capsule proper are necessary to the maintenance of the 
eyeball in its natural position. Enophthalmos will result from disease or 
injury of this fascia, if so situated and so extensive as to throw the balance 
of power in favor of the enophthalmic forces. This may be the case in 
paralysis of the smooth muscular fibres in the check ligaments, or in nutri¬ 
tional disturbance leading to atrophy or relaxation of the same. It may 
result from traumatic rupture of the check ligaments or of the orbital at¬ 
tachment of the fascia; or especially liable would it be to follow rupture of 
the posterior investing sheath of the eyeball. (W. T. Shoemaker.) 

Symptoms. —The symptoms of idiopathic bilateral enophthalmos are 
simply a recession of the eyeballs directly backward, with the characteristic 
sunken appearance of the eyes. The palpebral fissures are not narrowed. 

In traumatic enophthalmos the appearance is different. The eyeball is 
not only retracted,—it may be directly backward,—but is very often low¬ 
ered, with the axis directed upward. The palpebral fissure is always nar¬ 
rowed, and the appearance is that of an artificial eye (Nieden). As the 
visual axes are no longer in accord, diplopia is often complained of, and the 
excursions of the eyeball may be more or less limited, owing to the altered 
muscular relations, the radii of muscular action being shortened. Trau¬ 
matic enophthalmos is permanent. 

Exophthalmic Goitre (Parry’s Disease; Graves’s Disease; Basedow’s 
Disease).—The'three cardinal and characteristic symptoms of this disease 
are tachycardia, enlargement of the thyroid gland, and exophthalmos. The 
secondary symptoms are tremor, excessive sweating, nervousness, mental de¬ 
pression, apprehension, emaciation, pain and weakness in the extremities, 
brittleness of the nails, loss of hair (including eyelashes and eyebrows), 
increased lacrimation, conjunctivitis, diminished power of convergence, and 
other less common symptoms. Tremor is a very constant symptom, al- 


41 


642 


MODERN OPHTHALMOLOGY. 


though at times coming on only late in the disease, and has been classed by 
some writers as a cardinal symptom (Butler). 

Of the three cardinal symptoms, tachycardia is almost constant, and 
is the first to appear. One or both of the other symptoms may be absent for 
a long time. According to Gowers, exophthalmos is absent in about one- 
tenth of the cases and the goitre in about one-twelfth. The heart's action 
always reaches 100 per minute, and has been frequently noted at 200. 

The goitre may be unilateral or bilateral; but if bilateral it is gen¬ 
erally more marked on one side than on the other, and commences on that 
side. The exophthalmos may likewise be unilateral or bilateral, but is 
generally bilateral. It usually corresponds In side to that of the goitre, 
but several cases have been reported in which the goitre was on one side and 
the exophthalmos was on the opposite side. All degrees of exophthalmos 
are found, and very rarely actual dislocation of the eyeball has occurred. 
Many patients complain of an intolerable sensation of heat, which may lead 
them to cast aside their clothing and enables them to withstand low degrees 
of external temperature. The disease is one of early adult life, and prin¬ 
cipally effects females. Higgins places the percentage of cases occurring in 
women at 95 or 97 per cent. This is probably too high. Butler states the 
ratio to be 3 to 1. The same author calls attention to a family tendency. 

The special eye symptoms of exophthalmic goitre are important and 
interesting. Three phenomena affecting the lids are classic, and should 
be carefully sought for,'although they are not always to be found. 

Yon Graefe’s Sign consists of a want of a proper co-ordination be¬ 
tween the upper lid and the eyeball, when the latter is rotated-downward. 
Normally, in this action of the eyeball the upper lid follows proportionately, 
the amount of cornea covered by the lid remaining the same. In Graves’s 
disease the lid does not so follow; the cornea passes from under the lid, 
and a line of sclerotic becomes visible above. Lewin has observed this 
phenomenon in 55.5 per cent, of the cases of Graves’s disease, Hill Griffith 
in 13.2, Piissler in 17.6, and West in 14 per cent, of the cases. Fitzgerald 
has noted 4 cases of Graves’s disease with one-sided exophthalmos, and 
von Graefe’s sign corresponding to that side. Hack has seen 1 case of 
unilateral exophthalmos with von Graefe’s sign, in which the latter dis¬ 
appeared with the former. 

Wilbrand and Saenger have collected 39 cases of Graves’s disease classi¬ 
fied as follows: Exophthalmos in 37 cases—double in 33 and one-sided in 4. 
Of the cases of bilateral exophthalmos, von Graefe’s sign and Stellwag’s 
sign were found in 5. Yon Graefe’s sign was positive and Stellwag’s sign 
was questionable in 14, and both “signs” were questionable in 4. In all 4 
cases of unilateral exophthalmos both “signs” were found affecting the 
proptosed eye. In 6 cases exophthalmos and both “signs” were not to be 
found. Yon Graefe’s sign and Stellwag's sign without exophthalmos were 
found in 1 case, and in 2 cases Stellwag’s sign alone was found. Sharkey, 
in 613 cases, found von Graefe’s sign in 601. 


DISEASES OF THE ORBIT. 


643 


Several theories have been advanced for the explanation of this lid 
phenomenon. Yon Graefe believed it to be due to stimulation of the 
sympathetic nerves whereby the fibres of Muller’s palpebral muscle were 
contracted, thus holding the lid back. Dilation of the pupils, which should 
follow stimulation of the cervical sympathetic, is not, however, an accom¬ 
panying symptom. 

Sattler s explanation is a disturbance of the reflex and co-ordination 
centres (association centres). Against this theory has been urged an in¬ 
sufficient knowledge of these centres to warrant its acceptance. Also that 
long-continued disturbance of these centres should produce lasting results, 
which is not the case. 

Contraction of the levator palpebras muscle brought on by increased 
blood-supply is the theory of Ferri; and an insufficient of the orbicularis is 
that of Sharkey. 

Mobius and Bruns hold that in Graves’s disease there is an increased 
activity or power of the eye-musculature—an hypertonus of the levator 
muscle. Mobius believes that the primary phenomenon is Stellwag’s sign, 
and that this is followed by von Graefe’s symptom. 

Last must be mentioned the mechanical theory of Wilbrand and 
Saenger, which seeks to explain the phenomenon by a retrograde or reversed 
action of those muscle-fibres connecting the levator palpebras and the supe- 
lioi rectus muscles, which also have connection with the fornix of the con¬ 
junctiva. Normally, when the eyeball is rotated downward, traction made 
upon the fornix is transmitted through the above-mentioned fibres to the 
superior rectus and levator muscles, and the lid is able to follow the eyeball. 
Under certain circumstances, notably those found in certain cases of exoph¬ 
thalmic goitre, this relationship is disturbed, and the upper lid is mechan¬ 
ically not in condition to follow the eyeball. 

Stellwag s Sign consists of diminished frequency of and imperfect 
winking. A rapid succession of imperfect winks may be followed by a 
long pause without winking. The winking is imperfect in that the lids 
do not meet. The insufficiency is in part due to lessened reflex irritability 
of the cornea and retina. Sattler considers the lesion one of the reflex 
centres governing the retina, the cornea, and the conjunctiva. Swanzy 
thinks the imperfect winking is probably due to insufficiency of the 
orbicularis rather than to overaction of the levator. 

Infrequent nictitation may be found in hystero-epilepsy. It was also 
noted by Savage in a twenty-five-year-old woman who was otherwise 
healthy. He could examine the fundus with the ophthalmoscope for half 
an hour without the patient winking. 

On account of the imperfect closing of the lids, the lower portion of the 
cornea may suffer ulceration or pannus formation. 

Dalrymple’s Sign. —This is a retraction of the upper lid, with con¬ 
sequent widening of the palpebral fissure. It gives to the patient the 
characteristic stare and look of apprehension. Other conditions producing 


644 


MODERN OPHTHALMOLOGY. 


a similar widening of the palpebral fissure are orbital tumor (mechanically), 
stimulation of the cervical sympathetic, cocain (probably by action on the 
sympathetic), hysteria (occurring in women after childbirth), tetanus 
(spasm of the occipito-frontalis muscle), and complete amaurosis. 

Another phenomenon, which is, however, not characteristic of exoph¬ 
thalmic goitre, is tremor of the upper lid when an effort is made gently 
to close the eye (Bosenbach’s phenomenon). It is due to an antagonism or 
want of harmonious action between the palpebral portion of the obicularis 
and the levator muscle. Joffroy has noticed that when the patient holds 
the head down and attempts to look up without raising the head, the 
forehead remains smooth. Normally under such circumstances it should 
wrinkle. Periodic edema of the eyelids has been noted in a number of 
cases, and in one case three years before the disease declared itself (Wil- 
brand and Saenger). Discoloration of the skin, similar to that found in 
Addison’s disease, has been noticed in a few cases (Story). 

Falling of the evelashes and evebrows occasionallv occurs in the besfin- 
ning or in the course of the disease. Sattler attributes it to trophic dis¬ 
turbance. 

Conjunctivitis and lacrimation are common in cases with marked 
exophthalmos. The conjunctivitis is probably due to diminished sensi¬ 
bility of the conjunctiva and imperfect nictitation. The lacrimation and 
epiphora are thought by Berger to be due to stimulation of the sympathetic 
nerve, causing increased secretion from the lacrimal gland. Schmidt- 
Eimpler, on the other hand, considers these symptoms to be the result of 
mechanical irritation of the conjunctiva, which, on account of the proptosis 
and widened palpebral fissure, is more exposed than is normally the case. 
Another element in the causation is displacement of the puncta lacrimalia. 
The cornea suffers keratitis e lagophthalmo; opacities may appear on the 
lower portion, followed possibly by ulceration, or the unprotected portion 
of the cornea may become covered with pannus. One or both eyes may be 
destroyed. Mooren and Spalding have recorded cases in which enucleation 
was necessary on account of purulent chorioiditis. 

The exophthalmos is probably due to increase of the retrobulbar orbital 
contents. That there is a temporary increase in the amount of orbital fat 
has been clearly demonstrated; also there is an increased amount of blood 
in the orbital vessels. 

In accordance with the theory of sympathetic irritation, contraction 
of Muller’s orbital muscle, which covers the spheno-maxillary fissure, as 
well as contraction of other smooth muscle-fibres in the orbit, has been 
advanced as a causative factor of the exophthalmos. After death the ex¬ 
ophthalmos in part disappears, which, of course, favors the theory of mus¬ 
cular spasm and increased blood-supply. Knies states that dilated pupils 
as well as unequal pupils, with retained reflex activity, are frequently found. 
This he attributes to sympathetic irritation. 

Contrary to what might be expected, fundus changes in exophthalmic. 


DISEASES OF THE ORBIT. 


645 


goitre are' generally wanting, or, if present, are neither pronounced nor 
characteristic. In some cases the arteries are enlarged from vasomotor 
paralysis. They may equal the veins in calibre. Spontaneous arterial pul¬ 
sation was found by Becker six times in seven cases. The veins may be 
tortuous. Very rarely optic neuritis and optic-nerve atrophy are found. 

It should be remembered that exophthalmic goitre occurs often coinci- 
dently with other diseases of the nervous system, or constitutional diseases, 
such as hysteria, multiple sclerosis, bulbar paralysis, diabetes mellitus, or 
diabetes insipidus. Care must therefore be observed not to attribute to 
exophthalmic goitre changes which might be due to other diseases. 

Nature of the Disease— The pathology of exophthalmic goitre is as 
yet not known with certainty. For a full discussion of the various views 
on this subject works on nervous diseases and internal medicine must be 
consulted. Suffice it here to say that there are two chief theories, each of 
which is warmly supported by many competent observers. It seems, how¬ 
ever, that the greater amount of evidence is in favor of the disease being 
one primarily of the cervical sympathetic. Gordon says that the theory 
based on the influence of the sympathetic nerves covers all cases without 
exception. The other theory -is based on an increased thyroid secretion 
(hyperthyroidization) as well as a perversion of the secretion. This is 
held to be the primary cause, the other changes being produced secondarily. 

Prognosis. —In cases of pure Graves's disease this maybe said to be 
good. As mentioned above, however, there is a great tendency for Graves’s 
disease to occur coincidently with other diseases, in which the prognosis 
is not so favorable. Occurring in highly nervous and debilitated indi¬ 
viduals, the prognosis is not so favorable as when occurring in individuals 
who have previously enjoyed robust health, and are not members of that 
large class of neurotics. Williams, of Manchester, in a study of 24 cases 
found 6 to be fatal, complete recovery in 7, improvement in 7, the condi¬ 
tion unchanged in 3, and 1 case in which the patient was following his 
occupation, but the exact condition was unknown. The cases not dead or 
recovered were observed for a period of five years. 

Treatment.— Works on internal medicine and neurology must be 
consulted for the general treatment of exophthalmic goitre. At the present 
time surgical measures for the relief of this affection are being actively dis¬ 
cussed and tried. Such are simple exposure of the thyroid gland (exo- 
thyropexy), resection of the cervical sympathetic ganglia, ligation of three 
of the thyroid arteries, and partial extirpation of the gland. The ocular 
complications must be met as they arise. If the protrusion of the eyeball 
is sufficient to threaten the cornea from exposure, the palpebral fissure may 
be reduced in length by tarsorrhaphy. If more radical measures are neces¬ 
sary, the edges of the lids may be denuded and the two united by stitches in 
their entire extent, thus obliterating the palpebral fissure. The fissure may 
at the proper time be re-formed. Protection of the cornea is the important 
point to be kept constantly in mind. 


646 


MODERN OPHTHALMOLOGY. 


WOUNDS AND INJURIES OF THE ORBIT. 

* 

Under this heading we have for consideration simple contusion of the 
periorbital tissues (black eye), contused and incised wounds around the 
orbital margin, punctured and penetrating wounds of the orbital tissues, 
dislocation of the eyeball, fracture of the orbital walls, traumatic enoph- 
thalmos, and the entrance into the orbit of foreign bodies. 

Contusion of the periorbital tissues (black eye) results from blows at 
the entrance of the orbit, and in this country and in England is often re¬ 
garded as evidence of a preceding fistic encounter. Uncomplicated, the 
symptoms are those of any ordinary contusion. Blood is extravasated within 
the tissues of the lids and under the conjunctiva, causing the characteristic 
discoloration. The eyelids are swollen, often to the extent of complete 
closure. The eyeball suffers in proportion to its prominence and the amount 
of violence sustained. Emphysema indicates a fracture establishing com¬ 
munication with air-spaces, the ethmoid usually being fractured in these 
cases, thus opening the ethmoidal cells. 

The prognosis is good. The treatment aims at absorption of extrava¬ 
sated blood. To this end hot fomentations and pressure are of use. Re¬ 
cently a mixture of potter’s clay and glycerin, under the copyrighted name 
of antiphlogistin, has been used with good results. 

Injuries to the Orbital Margin.—Considering the sharpness and rigidity 
of the orbital margin, it is not surprising that rather moderate blows here 
frequently cause wounds which, though contused, in mode of production, 
often have the appearance of being incised. Owing to their contused 
nature, they have more or less of a tendency to suppurate. They should be 
carefully cleansed, stitched, and protected antiseptically. 

A much discussed question in former years was the occurrence of blind¬ 
ness following blows at the margin of the orbit, there being no demonstrable 
injury to the eyeball itself. That this has occurred many times is well 
known. The cause is to be sought in injury to the optic nerve, either from 
fracture in the neighborhood of the optic foramen or from hemorrhage into 
the orbit destroying the nerve by pressure. The supra-orbital and infra¬ 
orbital nerves are often injured by blows in this situation, causing anesthesia 
of the parts supplied, but there is no known association between these nerves 
and the optic nerve, as some writers have endeavored to prove. 

Wounds of the Soft Tissues of the Orbit are usually punctured in char¬ 
acter, They are caused, as a rule, by sticks, bayonets, umbrella ferrules, 
swords, etc., being thrust into the orbit, or by missiles of almost every 
kind striking at the orbital entrance. The bones may or may not be frac¬ 
tured; the periosteum may be injured or not, according to the depth of 
penetration, and the supra-orbital and infra-orbital nerves may be lacer¬ 
ated or severed. The ocular muscles may be cut or completely detached, the 
e}-eball ruptured, the optic nerve injured, or the eyeball dislocated. The 
symptoms and prognosis correspond with the extent of the injury. 


DISEASES OF THE ORBIT. 


G 47 

Treatment must meet the exigencies of the case, and must accord with 
general surgical principles. If the muscles are severed an attempt should 
be made to find the ends and unite them. If the eyeball is ruptured it 
should be saved, il possible, by repairing the rent and by careful antiseptic 
dressing. If such efforts are not warranted, it should be enucleated, or 
better still eviscerated and an artificial vitreous implanted. Probing of the 
wound must be done only with great care and scrupulous cleanliness. 

Luxation and Avulsion of the Globe.—As Barck has said, it is neces¬ 
sary to make a distinction between these terms. Luxation means that the 
eyeball lies in front of the lids, which close spasmodically behind it. The 
optic nerve and muscles are stretched, but their connection with the globe 
and with the other orbital structures is maintained. Avulsion indicates 
that, owing to rupture of the optic nerve and the severance of the majority 
or all of the extrinsic muscles, the connection is broken. 

Luxation may occur spontaneously, as in some cases of exophthalmic 
goitre, and in persons with abnormally shallow orbits and prominent eye- 



Fig. 365.— Avulsion of the eyeball. (Barck.) 


balls. It may also occur when, after the introduction of an eye speculum, 
the patient struggles, cries, or coughs. Depoutol saw a young man with 
an opisthognatous face who could dislocate his eyeball by blowing the nose 
violently. Generally, however, luxation results either from the impact 
of a large blunt foreign body; from self-inflicted injury produced by the 
insane with their fingers; or from the barbarous practice of “gouging,” 
which is said to be common among the natives of Uganda, ikfrica. In a 
few instances luxation has occurred in difficult instrumental deliveries. 

Avulsion is produced in this manner: the missile causative of luxation 
also acts as a lever, with sufficient energy to sever the optic nerve and 
lacerate the muscles. The unyielding orbital margin acts as a fulcrum. 
Avulsion has been caused by falls upon blunt projecting bodies. Thus, it 
has resulted from a fall upon keys which were in their locks, from the 
impact of a boar’s tusk, etc. 

Diagnosis.— Inspection will at once reveal the true condition. 

Prognosis. —In luxation the eyeball may or may not be ruptured. If 



648 


MODERN OPHTHALMOLOGY. 


torn, the case will probably require enucleation. If the globe is simply 
luxated the prognosis is generally favorable, although severe damage may 
have been done to the optic nerve, retina, chorioid, and lens. In avulsion 
the eye is lost. 

Treatment- —This consists in the earliest possible replacement of the 
eyeball within the orbit. It may be easily accomplished by separating the 
lids and gently pushing the globe backward. If it is attended with great 
difficulty, owing to the swelling of the lids and their tight constriction, 
retractors should be passed under the lids. In the event of failure, the 
outer canthus must be cut, the lids replaced, and the wound stitched. 
After reduction, rest and iced compresses are indicated, after which a com¬ 
press bandage should be worn for some time. If the eyeball is ruptured the 
indications for treatment are such as are -described elsewhere for this con¬ 
dition. If a case of avulsion is seen early and some of the muscles are still 
attached, an attempt may be made to stitch the globe into place with the 
hope of saving it for cosmetic reasons. If there is cause to believe that 
the germs of infection have been carried into the orbit, an enucleation 
should be made. 

Fracture of the Orbital Bones.—Orbital fracture is not rare after head 
injuries, and it is probable that, were we able to examine more exactly 
the walls of the orbit, many cases of fracture would be found which at the 
present time it would be impossible to diagnose. Many of the bones are 
exceedingly thin and delicate, and are placed between bones of much greater 
density. It is doubtful if they are thus better protected or are more liable 
to injury; a box car between two Pullman coaches in a railroad collision is 
always broken to splinters. 

The roof, the floor, and the inner wall of the orbit are all thin; the 
margin, the external wall, and the apex are quite dense and strong. Frac¬ 
ture involving the roof renders the patient liable to meningitis, and these 
cases frequently end fatally. Fracture of the floor establishes a communica¬ 
tion with the antrum, and often injures the infra-orbital nerve, while 
fracture of the inner wall opens the ethmoid cells. When air-spaces are 
broken into, emphysema of the orbital cellular tissue is a symptom. Frac¬ 
ture at the apex, if through the optic foramen, almost to a certainty destroys 
sight; if through the sphenoidal fissure, the third, the fourth, the ophthal¬ 
mic division of the fifth, and the sixth nerve are liable to injury, as well as 
are the ophthalmic and some smaller veins. 

Fracture of the outer orbital wall is the most easily diagnosed with cer¬ 
tainty, and is attended with results generally less'serious than when the 
fracture is elsewhere—with the exception of fracture limited to the margin. 
Small fragments of the orbital margin are not infrequently broken off, 
and cause very little trouble, becoming reattached, leaving only a slight 
inequality or deformity. It is probable, however, that in many of these 
cases there is a fissured fracture running backward into the orbit. The 
most dangerous fractures are those of the roof. 


DISEASES OF TTTE CEBIT. 


649 


I lie investigations of von Holder are instructive. He examined the 
bones in 124 cases of fracture of the skull, giving the following summary: 
Of the 124 cases, 84 were fractures at the base; and, of these, the fracture 
in 19 cases extended into the orbital roof. In 63 of the 84 cases he found 
a fissure or fracture running through the optic canal, always through the 
upper wall of the canal, and in some of the cases through the inner wall 
also. In 42 cases there was hemorrhage into the optic-nerve sheath, but 
never unless the canal was fractured. 

These figures throw much light on that rather large class of cases in 
which blindness follows head injuries. Such blindness mav come on at 
the time of injury and remain permanent; or, coming on at the time of 
injury, vision may ultimately be in part or wholly regained; or impairment 
of vision may appear at a time subsequent to the injury. The cases of 
immediate permanent blindness have probably sustained laceration or even 
complete section of the optic nerve, by bone fragments derived from a frac- 
tured optic canal. Subsequent improvement of vision would indicate the 
removal of the immediate cause of blindness. Such would be, for instance, 
relief of pressure upon the optic nerve. Pressure of a lesser degree, acting 
for a longer time, might cause a slow deterioration of the optic nerve, end¬ 
ing in partial or complete blindness at a time more or less remote from that 
of the injury. 

Some of these cases may show little or no ophthalmoscopic evidence 
of the injury at the time of its receipt. After extensive hemorrhage into 
the sheath of the optic nerve, the ophthalmoscope would show full veins and 
reduced arteries, fresh hemorrhages into the retina or even into the vitreous, 
blurring of the disc-margins, and retinal edema. The later appearances are 
those of neuroretinitis and optic-nerve atrophy. 

Cerebral symptoms, due to intracranial hemorrhage and inflammation, 
are to be expected when the roof of the orbit has been broken through, and 
it is worthy of note that they may be delayed a long time. In one case 
referred to by Noyes, cerebral symptoms appeared forty da}^s after injury 
by a foreign body. In a series of 52 cases of perforating wound of the 
orbital roof collected by Berlin, 41 died and 11 recovered. Of the 11 recov¬ 
eries, 3 were hemiplegic, 1 had persistent headache, and 1 became an imbe¬ 
cile. A symptom of importance, although not constant, when the cribri¬ 
form plate of the ethmoid is broken, is the dropping of a clear fluid from 
the nostril on the side of the injury. Bleeding from the nose is evidence of 
ethmoidal fracture; hemorrhage into the mouth has usually come through 
the antrum, and points to a fracture in the floor of the orbit. Hemorrhage 
into the orbit in some degree is a natural consequence of almost all orbital 
fractures, the former being in many cases only a symptom of the latter. 
Exophthalmos will depend upon the amount of hemorrhage. Enophthal- 
mos may follow fracture at certain situations in the orbit, but, owing to the 
still unsettled views as to the pathogenesis of this condition, it has been 
considered separately (page 640). 


650 


MODERN OPHTHALMOLOGY. 


The symptomatology of orbital fracture is always the same, however 
caused. The mode of production, however, whether by a blow, a thrust 
from a bayonet, sword, umbrella ferrule, or whether from a gunshot, is of 
considerable clinical value in showing the direction of immediate impact 
and in giving an idea as to the extent of injury. A punctured wound from 
below upward is much more to be feared than one from above downward 
or one directed toward the' temporal wall. Gunshot wounds are here, as 
elsewhere, very uncertain; the balls glance, and may take any or many 
directions. They are a little like bolts of lightning, deciding at the time 
which way they will go next. Furthermore, punctured and penetrating 
wounds may be probed and valuable information may be gained thereby. 
Probing, however, must be done with great care, cleanliness, and judgment. 
A probe in the hands of an unskillful surgeon may be a source of danger not 
exceeded even by the instrument causing the original injury. 

Treatment. —The treatment of fracture of the orbital bones and of 
the complications above described is that which general surgical principles 
dictate. The surgeon must keep before his mind always the very many 
contingencies, both near and remote, which may arise, and examine repeat¬ 
edly along every available line of investigation for signs which will indicate 
what is occurring within. At the same time he should avoid being med¬ 
dlesome, and, if through a penetrating wound he has with a probe once 
demonstrated to his satisfaction the existence of a fracture, he should be 
content to believe that any further probing can be only* harmful. If the 
injury has been inflicted by some tool or instrument, an examination of the 
tool or instrument should, if possible, be made, to determine if any portion 
of it is missing which may have remained in the orbit. Pus must be 
evacuated, injured structures (so far as possible) repaired, and function 
preserved. 

Foreign Bodies in the Orbit.—Foreign bodies may enter the orbit and 
remain for a long time undetected, or they may at once manifest them¬ 
selves in ways depending upon the amount of damage done. Small bodies— 
such as shot—are often very difficult or impossible to locate, and in many 
cases may remain within the orbital tissues, become encapsulated, and cause 
no trouble. 

The path of entrance of a foreign body into the orbit is, as a rule, 
sinuous, and therefore difficult satisfactorily to probe. As explained by 
Noyes, the body entering the orbit reaches the fasciae and forcibly drags the 
eyeball around toward the side of entrance; when the body has come to 
rest, the eyeball returns to its normal position, thus making the path sinuous 
and corresponding not at all to the direction of entrance. 

Fracture of the orbital walls or serious injury to the intra-orbital 
structures is more frequently found than not. if the foreign body enters 
with considerable force. Any foreign body which can be located should be 
at once removed. The locating of many foreign bodies has been much 
facilitated by the recent ingenious application of the Roentgen rays. Ex- 


DISEASES OF THE ORBIT. 


651 


cellent methods have been devised by Sweet and Leonard, of Philadelphia, 
and by Davidson, of London. 

If, after an injury which is apt to result in a foreign body being left 
within the orbit, a suppurating sinus remains, it is very good evidence that 
the body is still there. After all injuries of this kind, the patient should be 
carefully watched for a number of days for any signs of bone disturbance 
or pus-formation. Cases are on record of foreign bodies passing through 
the roof of the orbit into the brain. They have given no adequate svmp- 
toms at the time, but at a later period have caused death from brain- 
abscess. The patient should be carefully questioned as to the manner of 
injury, and all objects implicated in the propulsion of the offending body 
should be examined for broken fragments. Such a procedure is often use¬ 
ful in dealing with mechanics who are injured while at work. 

OPERATIONS ON THE ORBIT. 

Orbital operations are demanded for the removal of tumors, cvsts, and 
foreign bodies; for the repair of damage caused by the entrance of foreign 
bodies into the orbit; for the evacuation of abscess-cavities, the removal 
of necrosed bone; for resection of the optic nerve; and frequently for the 
relief of diseased processes in the adjacent cavities. Operations for pros¬ 
thesis in cicatricial orbits have been described in Chapter XVIII. 

Whatever operation is attempted in this region, the principles of 
modern surgery, regarding the preparation of the patient and that of the 
instruments, should prevail throughout. The proximity of the brain and 
the ready ways of access thereto should ever keep before the operator’s mind 
the possibility of subsequent meningitis. 

Removal of Tumors.—In dealing with intra-orbital cysts and benign 
tumors the prime object should be to remove them without destroying the 
eyeball or the optic nerve. If the tumor be malignant, it is generally ad¬ 
visable to remove the eyeball and in some cases to clean out the entire orbit 
(exenteration). Knapp always approaches these cases in an exploratory 
manner, being fully prepared at once to continue the operation to meet the 
exigencies of the case. This is a wise procedure, for the extent and attach¬ 
ments, as well as the character, of many growths cannot be determined 
until they are brought to view. 

Growths situated at or presenting near the orbital entrance can be 
exposed by making a sufficient incision concentric with the orbital margin, 
separating the tissues with a blunt instrument, and displacing the eyeball 
and adnexa upward, downward, inward, or outward as the case requires. If 
within the muscle-cone, access is obtained by exposing the internal rectus 
muscle, passing a silk thread through it near its insertion, then detaching 
the muscle at its insertion, and with the thread drawing and anchoring the 
muscle away from the eyeball. Strong rotation of the eyeball outward will 
open up the space within the cone. The growth may then be stripped from 


652 


MODERN OPHTHALMOLOGY. 


its attachments as far as possible and removed. This done, the rectus 
muscle is reattached at its original insertion in the sclera. In this manner 
the optic nerve is also to be exposed, and, if resection is required, one hook 
is passed around it near the globe and a second hook worked backward as 
far as necessary, the intervening nerve being the portion for resection. 

Kronlein’s’ Operation, practiced first in 1887, is for the exposure of 
the deep portions of the orbit. It is a difficult and tedious operation, but 
if properly done deep-seated growths or foreign bodies can be much more 
readily removed than by working from the orbital entrance. The opera¬ 
tion consists of a temporary osteoplastic resection of the outer orbital wall. 
An incision starting from the temple is made to pass through the upper, 
outer orbital margin, then, curving within the margin (to the nasal or 
median side), carried backward, again crossing the orbital margin a little 
below its horizontal meridian and ending in the temple above the zygomatic 
bone. The incision in its two crossings of the orbital margin, and the 



A-B, Bone resection. 


A-B, Skin incision, 


Fig. 366.—Kroiilein’s operation 


included curve is carried down to the bone. The periosteum of the orbital 
surface of the outer wall is then detached as far back as the anterior end 
of the spheno-maxillary fissure. By chiseling from the upper end of the 
denuded margin obliquely downward to the spheno-maxillary fissure, and 
from the lower end of the margin to the anterior end of the fissure, or 
by use of a dental engine and circular saw, a wedge-shaped piece of bone is 
loosened. This, with its skin and muscle attachments, may now be drawn 
outward, thus permitting of ready access to the deeper portions of the 
orbit. The periosteum must be slit before the intra-orbital contents can be 
reached. When the work within the orbit has been completed, hemorrhage 
must be checked, after which the resected bone is pushed into place, the 
periosteum is united with catgut sutures, and the skin-flaps are united with 
silk. The after-treatment consists of a compress bandage and rest in bed 
until healing is well under way. 



DISEASES OF THE ORBIT. 


653 


Exenteration of the Orbit consists in removal of the orbital contents 
in their entirety. Its indication is usually malignant disease which is no 
longer isolated, but involves many or all of the orbital structures. If the 
entire periosteum is healthy, it may be allowed to remain (partial exen¬ 
teration) ; if diseased, it must be stripped off (total exenteration). 

The first step of the operation is to divide the outer canthus; an incision 
is then made through the conjunctiva of the everted lower lid down to and 
along the lower margin of the orbit. A similar incision is carried along the 
outer, upper, and finally along the inner margin. If the exenteration is to 
be total, the periosteum is divided along the margin and is stripped from the 
bone back to the apex; the apical mass of tissue is then divided with heavy 
curved scissors or with a sharp curette. The orbital contents are then 
removed enveloped in the periosteum. 

If the exenteration is to be partial, the preliminary steps of the opera¬ 
tion are the same as for total exenteration; then, instead of dividing the 



Fig. 367.—Modification of Kronlein’s operation. (Parinatjd and Rociie.) 

periosteum, the soft tissues are separated from it with scissors and the apex 
is cut or curetted as above. In either case the eyeball may first be enucleated 
in the regular way or not, as desired. Hemorrhage in this operation is gen¬ 
erally copious, but is easily controlled by packing aided by hot water. The 
dressing consists of sterile gauze packing, which should remain undisturbed 
for two or three days before redressing in the same manner. 

In stripping the orbital bone of the periosteum the thinness of the 
bones at certain points should not be forgotten, and great care should be 
exercised, especially at the roof. If the lids are also involved in cases of 
malignant disease, it then becomes necessary to remove them along with the 
orbital contents. The resulting deformity is, of course, much increased. 
The entire orbit may be closed in or excluded by taking flaps of skin from 
the forehead, temple, and cheek. The deformity is still considerable, but 
far less revolting than when the orbit is uncovered. 






CHAPTER XX. 


ANOMALIES OF THE MUSCULAR APPARATUS. 

By WILLIAM ZENTMAYER, M.D., of Philadelphia, 

One of the Attending Surgeons to Wills Eye Hospital and Ophthalmic Surgeon 

to St. Mary’s Hospital. 

In order to understand the phenomena resulting from disturbed action 
of the orbital muscles it is essential to have a clear conception of the indi¬ 
vidual and associated action of these muscles under normal conditions. 
The movements of the eyeball are effected by means of three pairs of 

T T 




Fig. 36S.—Scheme of the axes of rotation of the ocular muscles. 

The figure at the left: T-T, antero-posterior axis of the eyeball; C-C, axis of rotation 
of the superior and inferior recti of the left eye. The figure at the right: P-P, axis of rota¬ 
tion of the superior and inferior obliques of the left eye. 

muscles, which move the eye about the centre of rotation. Each muscle of 
a pair is the antagonist of the other. 

All movements of the eyeballs are to be considered as starting with the 
eyes in the primary position —that is, with the head erect and the eyes 
directed straight forward to a distant point on the visual plane. 

Action of the Muscles.—The muscular plane of the internal and ex¬ 
ternal recti corresponding to the horizontal plane of the eyeball, these mus¬ 
cles move the globe respectively directly inward and outward about a vertical 
axis. 

Owing to the attachment of the superior and inferior recti being 
anteriorly and templeward relative to their point of origin, the mus¬ 
cular plane of each is inclined to the antero-posterior axis of the globe, 
forming with it an angle of about 25 degrees, and consequently the muscles 
move the eye about an axis directed from before and nasalward to behind 
and templeward, forming with the antero-posterior axis an angle of about 
(654) 








ANOMALIES OF THE MUSCULAR APPARATUS. 


655 


65 degrees. The superior rectus, therefore, does more than move the eye 
upward, associating with this principal action an inward movement and a 
partial rotation of the cornea (torsion), so that the vertical meridian be¬ 
comes inclined by its upper extremity toward the nose; while the inferior 
rectus moves the eyeball downward and inward and inclines the vertical 
meridian of the cornea outward by its upper extremity. The supra- and 
infra- ducting power of these muscles is greatest when the eyeball is turned 
outward, as then the horizontal axis of the globe coincides most nearly 
with the axis of rotation of these muscles; while the torsion action is most 
pronounced when the eyeball is turned inward, as. in this position the 
antero-posterior axis of the globe coincides most nearly with the axis of 
rotation of these muscles. 

The attachment of the obliques being posteriorly and templeward 
relative to the point of mechanical origin, the muscular plane is in- 


Inf O 
Ext R 



Jrrt R 

Fig. 369.—Muscles associated in moving the eyeballs in the directions 

indicated by the arrows. 

dined to the antero-posterior diameter of the globe, forming with it an 
angle of about 50 degrees. Consequently these muscles move the eyeball 
about an axis directed from anteriorly and templeward to posteriorly and 
nasalward, forming with the antero-posterior axis of the eyeball an angle 
of about 40 degrees. The superior oblique, therefore, turns the eyeball 
downward and outward and inclines the vertical meridian of the cornea in¬ 
ward by its upper extremity. The inferior oblique turns the eyeball upward 
and outward and inclines the vertical meridian of the cornea outward by its 
upper extremity. The supra- and infra- ducting power of the obliques is 
greatest when the eyeball is turned in, as in that position the horizontal 
axis of rotation of the globe coincides most nearly with the axis of rotation 
of the obliques, and the torsion power is greatest when the eyeball is turned 
outward, as in this position the antero-posterior axis of the globe agrees 
most nearly with the axis of rotation of these muscles. 





656 


MODERN OPHTHALMOLOGY. 


As in accordance with the law of Listing all rotations of the eyeball 
must be “about axes in a vertical plane passing through the centre of 
motion of the eye perpendicular to the visual line in its primary position ” 
(Maddox), it follows that the independent physiologic action of any muscle 
which would revolve the eye about an axis inclined from either the vertical 
or horizontal is impossible; consequently all movements of the globe other 
than the lateral must be accomplished by the co-ordinate action of such 
muscles as would have the resultant axis in this plane. 

The outward movement of the eyeball is effected by the external rectus, 
aided by the superior and inferior obliques. 

The inward movement of the eyeball is effected by the internal rectus, 
aided by the superior and inferior recti. 

The upward movement of the eyeball is effected by the superior rectus 
and inferior oblique acting together, the lateral recti serving to guide the 
eyeball. 

The downward movement of the eyeball is effected by the inferior 
rectus and the superior oblique acting together, the lateral recti serving 
to guide the eyeball. 

In the upward movement the inward rotation and the slight inward 
inclination of the globe which would result from the action of the rectus 


alone are opposed by the counter-action of the inferior oblique. 

In the downward movement the inward rotation and the slight outward 


inclination of the globe which would result from the action of the rectus 
alone are opposed by the counter-action of the superior oblique. The mus¬ 
cles associated in turning the eye into oblique positions may be learned 
from Fig. 369. The eye should be capable of an upward rotation of at 
least 33 degrees, downward of at least 50 degrees, nasalward and temple- 
ward from 48 to 53 degrees (Stevens). 

Binocular Movements.—The turning of the eyeballs to the right is ac¬ 
complished by the associated action of the external rectus and the obliques 
of the right eye with the internal rectus and the superior and inferior recti 
of the left eye; to the left, by the associated action of the external rectus 
and the superior and inferior obliques of the left eye with the internal rectus 
and the superior and inferior recti of the right eye. 

The muscles associated in oblique conjugate deviations are:— 


Up and to the right 


R. E. 

Superior rectus, inferior 
rectus. 

oblique, 

and 

external 

L. E. 

Superior rectus, inferior 
rectus. 

oblique, 

and 

internal 


Up and to the left 


R. 

E. 

Superior 

rectus. 

rectus, inferior 

oblique, 

and 

internal 

L. 

E. 

Superior 

rectus. 

rectus, inferior 

oblique, 

and 

external 


Down and to the right « 


R. E. 
L. E. 


Inferior 

rectus. 

rectus, 

superior 

oblique, 

and 

external 

Inferior 

rectus. 

rectus, 

superior 

oblique. 

and 

internal 





ANOMALIES OF THE MUSCULAR APPARATUS. 


657 


' R. 

Down and to the left J T 


E. 

1 nferior 

rectus, 

super 


rectus. 



E. 

Inferior 

rectus, 

superi 


rectus. 




r oblique, and internal 
• oblique, and external 


Convergence of the visual lines results from the associated action of 
the internal recti of both et'es. 

General Symptomatology.—When, from any cause, one of the extra- 
ocular muscles fails to act in association with its physiologic fellow (asso¬ 
ciated antagonist—von Graefe) of the other eye, disturbed binocular vision 
results, varying from a mere confusion or blurring of the outlines of objects 
to actual diplopia, provided that binocular vision previously existed, that 
the false image falls upon the retina, and that there is no associated paraly¬ 
sis of the palpebral levator muscle. 

Diplopia (double vision) results from the fact that images for both 
eyes of the same external object fall upon dissimilar points of the two retinae, 
and are in consequence projected to different parts of the visual field. 

Primary Deviation is the deviation of the affected eye when the sound 
eye fixes. It is often appreciable only when the eyes are turned somewhat 
in the direction of the action of the affected muscle. 

Secondary Deviation is the deviation which the sound eye undergoes 
when the affected eye is made to fix. It is always greater than the primary 
deviation, because the excessive innervation which is necessary to cause 
the affected eye to fix is transmitted also to the sound associated muscle of 
the fellow-eye, and produces a corresponding excessive excursion of the 
eye in the direction of the action of this muscle. Example: With a paraly¬ 
sis of the external rectus of the right eye the object to be fixed is held at a 
distance of about 40 centimetres in front and slightly turned to the right 
side, and the patient is commanded to look sharply at it, the other eye being 
covered by a card. The cover is now transferred to the affected eye, when, 
in order to fix the object, the sound eye will be seen to make a large outward 
excursion, which is evidence that it must have been turned in excessively 
while under cover. In other words, the internal rectus muscle of the sound 
eye was receiving innervation in excess of the amount required to keep the 
visual line directed to the object. 

Projection of the False Image .—The patient refers the false image to 
that position in space which (in the normally directed eye) an object would 
hold having its image formed on the point of the retina now occupied by 
the false image. The exact position of the projected image can be deter¬ 
mined by giving to the eye its normal direction (which would be accom¬ 
plished by action of the affected muscle) and projecting a line from this 
retinal point through the centre of rotation of the eye into space. Example: 
With a paralysis of the external rectus muscle, the internal rectus draws the 
e} r eball inward, so that the image of an object fixed by the fellow-eye will, 
in the affected eye, fall to the inner side of the fovea. Now, this point of 
the retina, under normal conditions, receives the image of an object situ- 


42 



658 


MODERN OPHTHALMOLOGY. 


ated to the temporal side, and it will be in that locality that we will find 
that the patient refers the false image. 

Limitation of the Movements of the Globe is always in the direction 
of the action of the affected muscle, and varies from abolition to a degree 
so slight as to be detectable only by accurate determination of the field of 
fixation. With both eyes open, the patient is directed to follow, with the 
eyes, the movement of the tip of a pencil, or like object, which is carried in 
a systematic manner through the principal meridians. The ability or in¬ 
ability of the two eyes to follow in an equal degree is determined by com¬ 
paring the distances between the margin of the cornea and the edges of the 
lids, in the upward and downward movements, and the canthi in the lateral 



Pig. 370.—Illustrating the projection of the false image. 

The right eye is convergent; hence the diplopia is homonymous. The red line represents 
the eye restored to its normal position, showing that the retinal point, e, which received the 
image when the eye was deviated, would receive the image of an object situated at Sp, when 
the eye is in the normal position. Hence it is to this position in space that the patient refers 
the false image. 


movements in the two eyes: or by comparing the position of the corneal 
images of some distant object when the eyes are moved in the different 
directions. The field of fixation is determined in the same manner as is 
the visual field, except that the patient is directed to follow with the affected 
eye the test-object (which may consist of a small printed letter) *as it is car¬ 
ried outward along the arc of the perimeter and make known when he can 
no longer decipher it. This method is of especial value where the defect 
is slight or where more than one muscle is affected. Example: In paralysis 
of the inferior oblique the field of fixation would show contraction above 
and to the outside. Stevens has designed an instrument, which he terms a 
tropometer, for measuring the rotation of the eyes in all directions. It con- 




ANOMALIES OF THE MUSCULAR APPARATUS. 


659 


sists of a telescope in which an aerial image of the cornea is formed near 
the eyepiece (see page 110). 

False Muscular Projection arises from disturbed relation between in¬ 
nervation and muscular action, so that a false, exaggerated conception of 
the direction of the eye is obtained, because of the amount of innervation 
required to bring the visual axis to bear on the object. It manifests itself 
in an inability properly to judge of the location of objects. Example: 
In paralysis of the internal rectus muscle of the left eye, if the patient be 
asked to place his finger on an object held slightly toward the right side, lie 
will direct his finger farther to that side than the object is situated, because 
the amount of innervation required would, under normal conditions, have 
directed the visual line to that point. 



Fig. 371.—Paralysis of the internal rectus of the right eye, producing 

crossed diplopia. 

The red glass is before the right eye. 

Vertigo results from the diplopia and from defective orientation—that 
is, inability to judge correctly of the relative location of objects in space. 

Compensatory Turning of the Head to Avoid Diplopia. —The explana¬ 
tion of this symptom is that the patient, being unable to turn the affected 
eye, turns the head so as to bring the visual line to bear upon the object 
fixed by the sound eye—that is, the head is turned in the direction of the 
defective movement of the eye. Example: In paralysis of the internal 
rectus of the left eye the head is carried to the right. 

Method of Examination. —The examination for the determination of 
the characteristics of the diplopia should be carried on in a dark-room 
with the patient seated. The greatest care must be taken that the head is 
held erect and motionless, lest by moving the head the patient compensate 
for the deviation of the eye. In order better to differentiate the images a 


660 


MODERN OPHTHALMOLOGY. 


red glass should be held before one eye. The use of a frame is to be avoided, 
as in extreme excursions of the eyeball it may obstruct the vision and lead 
to false conditions. The examiner should stand with a lighted candle about 
three metres in front of the patient and direct him to follow the movements 
of the light with his eyes, and note the relation of the two images as the can¬ 
dle is carried along certain meridians through which the eye may be nor¬ 
mally moved. The room should be large enough to prevent projection of the 
images upon the side-walls. In some instances the image falls far out on the 
periphery of the retina, or perhaps on the papilla (Wallace) and is not rec¬ 
ognized. In such a case a prism, so placed as to bring the image on to a sen¬ 
sitive part of the retina, will render the diplopia manifest. By this method 



Fig. 372.—Paralysis of the external rectus of the right eye, producing 

homonymous diplopia. 

The red glass is before the right eye. 

no great difficulty will be experienced in arriving at a proper diagnosis if but 
one muscle be paralyzed. Should it be evident that two or more muscles are 
affected, a prism will sometimes be found of service in eliminating the 
diplopia resulting from the paralysis of one muscle, and thus will simplify 
the further study of the images. As a rule, however, in these cases it will 
be found necessary to mark upon a blackboard the relation of the images 
as they appear in various parts of the field of fixation. 

General Principles .—The distance between the images increases when 
the light is carried in the direction of the action of the affected muscle. 
The fainter image belongs to the affected eye. When the images are 
crossed ,—that is, when the red image is seen to the opposite side of the nor¬ 
mal image, from the eye before which the red glass has been placed,—an 
adductor muscle is affected, and one of the vertical straight muscles, if the 



ANOMALIES OF THE MUSCULAR APPARATUS. 


661 


images are not on the same horizontal plane. Should the red image be 
seen on that side of the normal light corresponding to the eye before which 
the red glass has been placed, the images are said to be homonymous, and it 
indicates an affection of one of the abductor muscles, and of one of the 
obliques if the images are not on the same horizontal jilane. 

A greater separation of the images occurs when the eyes are directed 
to the image belonging to the affected eye. 

The false image has the position and the inclination which the affected 
muscle gives to the eyeball when acting normally. The remembrance of 
this principle and of the facts necessary to apply it is a sine qua non for the 
solution of the succeeding problems. 

Special Symptomatology. —Paralysis of the External Eectus 
(Horizontal Diplopia). —Images are upon the same plane, homonymous. 


A A 


Paralysis of right 
external rectus. 


A A 


Paralysis of right 
internal rectus. 



Paralysis of right 
superior rectus. 



Paralysis of right 
inferior rectus. 


A 




Paralysis of right Paralysis of right 

superior oblique. inferior oblique. 

Eig. 373.—Position of the images in ocular paralyses. 

The true image is black, the false is red. 


and parallel; separation increases in the direction of the affected side, and 
also in looking downward. 

Primary deviation—inward. 

Secondary deviation—inward. 

Limitation of excursion—outward. 

Field of fixation-—contracted outward. 

Inclination of head—turned toward the affected side. 

False muscular projection—toward the affected side. 

Internal Eectus (Horizontal Diplopia). —Images are upon the 
same plane, crossed and parallel; separation increases toward the sound 
side, and also in looking upward. 

Primary deviation-—outward. 

Secondary deviation—outward. 

Excursion-—limited inward. 

Field of fixation—contracted inward. 

Inclination of head-—turned toward the sound side. 

False muscular projection—toward the sound side. 


















662 


MODERN OPHTHALMOLOGY. 


Superior Rectus (Diplopia in the Upper Field). —Images are 
superposed (vertical diplopia) and slightly crossed; false image leans by 
upper extremity toward the sound side. Vertical separation increases in the 
upper field, and is greater up and out. Lateral separation increases toward 
the sound side, and the inclination is greatest toward the sound side. 


Primary deviation—downward and slightly outward. 

Secondary deviation—upward and toward the sound side. 

Excursion—limited upward. 

Field of fixation—contracted upward and inward. 

Inclination of the head—turned up and toward the sound side, with a slight 
inclination toward the shoulder of the sound side. 

False projection—up and toward the sound side. 

Inferior Rectus (Diplopia in the Lower Field). —Images are 
superposed (vertical diplopia) and slightly crossed ; false image leans by its 
upper extremity toward the affected side. Vertical separation increases 
downward, and is greatest down and out. Lateral separation increases 
toward the sound side, and the inclination is greatest toward the sound 
side. 


Primary deviation—upward and slightly outward. 

Secondary deviation—downward and toward the sound side. 

Excursions—limited downward, and downward and inward. 

Field of fixation—contracted downward and inward. 

Inclination of the head—downward and toward the sound side, with a slight 
inclination toward the shoulder of the affected side. 

False projection—downward and to the sound side. 

Superior Oblique (Diplopia in the Lower Field). —Images are 
superposed (vertical diplopia) and slightly homonymous; false image leans 
by its upper extremity toward the sound side. The vertical separation in¬ 
creases downward and is greatest down and in. The lateral separation 
increases toward the affected side, and the inclination is greatest toward 
the affected side. 

Primary deviation—upward and slightly inward. 

Secondary deviation—downward and toward the affected side. 

Excursions—limited downward, and downward and outward. 

Field of fixation—contracted downward and outward. 

Inclination of the head—downward and toward the affected side, with a slight 
inclination toward the shoulder of the sound side. 

False projection-—below and toward the affected side. 

Inferior Oblique (Diplopia in the Upper Field). —Images are 
superposed (vertical diplopia) and slightly homonymous; false image leans 
by its upper extremity toward the affecte'd side. The vertical separation in¬ 
creases upward and is greatest up and in. The lateral separation increases 
toward the affected side, and the inclination is greatest toward the affected 
side. 


ANOMALIES OF THE MUSCULAR APPARATUS. 


663 


Primary deviation—downward and inward. 

Secondary deviation—upward and toward the affected side. 

Excursions—limited upward, and upward and outward. 

Field of fixation—contracted upward and outward. 

Inclination of the head—held upward and turned slightly toward the affected 
side, with a slight inclination toward the shoulder of the affected side. 

False muscular projection—above and toward the affected side. 

Occasionally in paralysis of either the superior oblique or of the inferior 
rectus the false image appears closer to the patient than does the true one. 
This has been explained by the fact that the false image, which is the lower 
one, must appear closer to the patient if he projects them on to a horizontal 
plane as represented by the floor. 

Crossed diplopia is occasionally met with in paralysis of either oblique. 
The explanation of this anomaly given by Mauthner is that a previously 
existing latent exophoria has become manifest. 

Paralysis of tile Oculomotor Nerve.— When all the muscles sup¬ 
plied by the third nerve are affected, the following characteristic clinical 
picture will be observed: Ptosis with compensatory contraction of the 
occipito-frontalis muscle, outward and slightly downward deviation of the 
eye, loss of all movements of the globe except outward and outward and 
downward, fixedly semidilated pupil, and loss of accommodation. There 
is diplopia in all parts of the field except downward and outward. 

Example of tile Clinical Method of Determination.— Having 
arranged as directed in the paragraph on “Method of Examination” (page 
659), with the red glass before the right eye, the patient will see two lights 
—one red and the other of the natural color. Inquiry brings out the fact 
that the lights stand one almost above the other, with the red one the 
higher and a little to the patient’s left. This determines that either a 
levator or a depressor is affected, and, as the images are crossed, it must be 
one of the straight muscles. On carrying the candle into the upper field 
the patient states that the distance between the lights increases, from which 
we decide that the affected muscle is a levator, and of the right eye, as the 
image of that eye stands the higher. Should the patient fail to realize 
that the images do not stand one directly above the other, the diagnosis 
cannot at this stage be made, and the light must be carried into the superior 
lateral fields in order to accentuate the inclination of the false image. 
If the patient answers that this follows when the candle is carried toward 
the sound side, it renders possible a diagnosis of paralysis of the right supe¬ 
rior rectus muscle. 

Duane considers that paralysis of the obliques and of the superior and 
inferior recti can be diagnosed from the behavior of the vertical diplopia 
alone, and with this idea in view he has evolved a simple method for the 
determination of the muscle paralyzed. He divides the elevators into two 
groups: The first includes those having the greatest elevating effect when 
the eyes are turned to the right (the right superior rectus and the left in¬ 
ferior oblique). These he terms riglit-liand elevators. The second group 


MODERN OPHTHALMOLOGY. 


(564 

includes those having the greatest elevating effect when the eyes are turned 
to the left (the left superior rectus and the right inferior oblique)— left- 
hand elevators. The depressors are similarly grouped. The right-hand 
depressors are the right inferior rectus and the left superior oblique; and 
the left-hand depressors are the left inferior rectus and the right superior 
oblique. Duane summarizes as follows:— 

“A vertical diplopia increasing not only up, but markedly up and to 
the right, means paralysis of a right-hand elevator (right superior rectus 
or left inferior oblique) ; and one that increases particularly up and to the 
left means paralysis of a left-hand elevator (right inferior oblique or left 
superior rectus). In either case a right diplopia (vertical diplopia, with 
the image of the right eye below) means paralysis of the muscle of the left 
eye, and left diplopia (vertical diplopia with the image of the left eye 
below) means paralysis of the muscle of the right eye. 

“A vertical diplopia increasing down and to the right means paralysis 
of a right-hand depressor (right inferior rectus or left superior oblique), 
and vertical diplopia increasing as the eyes are carried down and to the left 
means paralysis of a left-hand depressor (right superior oblique or left 
inferior rectus). In either case if the image of the right eye is below 
(right diplopia) it is the muscle of the right eye that is paralyzed, and if 
the image of the left eye is below (left diplopia) it is the muscle of the left 
eye that is paralyzed.” 

Werner’s scheme (Fig. 374) will be found of assistance in recalling the 
relation of the images in paralysis of the muscles. The broken lines rep¬ 
resent the false images. The method of applying it may be illustrated by 
considering a paralysis of the right superior rectus. The diagram shows 
at once that the diplopia occurs in the upper field, and that the images are 
crossed, the false one standing the higher and being inclined by its upper 
extremity toward the sound side. 

Etiology.—Clinically considered, the causes of ocular paralysis may 
be divided into two classes— central and peripheral, accordingly as the 
lesion lies between the cortex and the apparent origin of the nerves at the 
base of the brain or from the latter point to their peripheral terminations. 
The first class may be subdivided into cerebral (between the cortex and the 
nuclei), nuclear, and fascicular. The second class may be subdivided into 
basal and orbital. 

Cerebral Lesions. —These can produce only conjugate or associated 
deviations, because this region presides over the yoked action of the ocular 
muscles only. Stimulation of the right hemisphere causes deviation of the 
eyes to the left, and stimulation of the left hemisphere causes deviation of 
the eyes to the right. A lesion which would act destructively to this re¬ 
gion, either directly or distantly, would paralyze this movement, and the 
eyes would be turned in the opposite direction by the action of the opposing 
conjugate acting muscles. The eyes would therefore be turned toward the 
lesion and away from the paralyzed side of the body. Irritating lesions 


ANOMALIES OF THE MUSCULAR APPARATUS. 


6G5 


would have the opposite effect, and here the eyes would be turned away 
from the lesion and toward the convulsed side of the body. 

N uclear Palsies. —Nuclear lesions may give rise to “conjugate lateral 
paralysis” (Swanzy) the relation of the deviation to the site of the lesion 
being the reverse of that arising from a cerebral lesion, as the sixth nerve 
presides over the conjugate action of the external rectus muscle of the same 
side and the internal rectus of the opposite side. Convergence would be 
retained, but the individual action of the externus would likely be para¬ 
lyzed. 

Paralysis of convergence from a lesion of the convergence centre, which 
is supposed to be in the aqueduct of Sylvius, is occasionally seen. It may 
be associated with paralysis of accommodation, and is at times accompanied 


L S R 


R S R 



L I R 


R I R 


B 



B 


Fig. 374.—Mnemonic scheme of ocular paralyses. (Werner.) 


by paralysis of sursumvergence and deorsumvergence. It is most frequently 
met with in disseminated sclerosis. 

Nuclear Palsy, or Ophthalmoplegia, is the result of a lesion affect¬ 
ing the nuclei of the ocular muscles in the floor of the fourth ventricle and 
in the aqueduct of Sylvius. The external muscles alone may be involved 
(external ophthalmoplegia) or the internal muscles alone (internal ophthal¬ 
moplegia), or both groups together may be affected (mixed ophthalmo¬ 
plegia). It may be congenital or acquired. The acquired type appears in 
two forms, acute and chronic. 

Acute Ophthalmoplegia is a rare disease, usually beginning with head¬ 
ache, vomiting, and dizziness, followed by rapid paralysis of all the ocular 
muscles. The disease ends speedily in death. The lesion is due to hemor- 





GG6 


MODERN OPHTHALMOLOGY. 


rhagic extravasations. The cause is usually alcoholism or, more rarely, 
other poisons and traumatism. 

Chronic Ophthalmoplegia may be due to syphilitic arteritis or may 
occur as a complication of tabes, disseminated sclerosis, general paralysis, 
multiple neuritis, and exophthalmic goitre. It also occurs after diphtheria 
and, rarely, after measles, scarlet fever, and influenza; from poisoning by 
alcohol, tobacco, lead, carbon dioxid, sulphuric acid and ptomains; and 
as the result of traumatism. The affection begins by involvement of one 
or more of the external muscles and progressively involves all. The internal 
muscles are usually spared, but may be affected independently or in con¬ 
junction with the external muscles. The third nerve is most frequently 
affected, but the degree and frequency with which the levator is involved 



Fig. 375.— Ophthalmoplegia. (Author.) 


The patient is attempting to open his eyes. 

is moderate. It is usually bilateral. The prognosis, as is to be inferred 
from the name, is unfavorable. Treatment must be directed to the cause. 
The indications will generally best be met by the use of large doses of potas- 
siuin iodid and of strychnin. 

Fascicular Palsies. —Ocular paralyses due to lesions situated be¬ 
tween the nuclei and the base of the brain are frequently associated with 
paralysis of the opposite side of the body, the so-called alternate paralysis. 
The differential diagnosis between this group and those due to lesions of 
the nuclei and of the base is often impossible. Cases with upward deviation 
of one eye and downward deviation of the other have been seen but rarely, 
with lesions- in the crura cerebelli. 

Peripheral Paralysis.— The most common causes of peripheral 
paralysis are syphilis and rheumatism. Whether the paralyses met with 




ANOMALIES OF THE MUSCULAR APPARATUS. 


GG7 


in diabetes, diphtheria, herpes zoster ophthalmicus, influenza, and the 
various forms of poisoning are not at times peripheral, and not always 
nuclear, is still undecided. 

Basal Lesions .—These are the most frequent causes of ocular palsies, 
and are usually of such a nature as to operate through direct pressure, as 
in meningitic exudate or tubercle, neoplasm and gumma either of the 
meninges or of the brain-substance, ostitis and periostitis, hemorrhage, 
aneurism, or fracture. 

Any or even all of the muscles of one or of both eyes may be affected and 
other cerebral nerves may be involved. When ocular palsies are accom¬ 
panied by monocular blindness; bitemporal hemianopsia or homonymous 
hemianopsia, associated with the hemianoptic pupillary reaction sign; or 



Fig. 376.—Ophthalmoplegia. (Author.) 

The lids are held open to show the position of the eyeballs. 


where, in the oculomotor palsies, the internal muscles are not involved, 
they are usually of basal origin. 

Recurrent Third-Nerve Paralysis .—This is a rare affection usually seen 
in youth and in the female sex. It *is always monocular, and in the recur¬ 
rences the same nerve is always affected. The attacks last from days to 
months, and the intervals vary from a period of from ten days to a year’s 
time. In the few autopsies recorded the lesion has been of the nerve- 
trunk. 

A similar affection of the sixth nerve has been observed. 

Orbital Lesions affect the muscles and nerves principally mechanically. 
The lesion may be aneurism, neoplasm, or inflammation of the orbital 
tissues or of the accessory sinuses, periostitis, fracture at the sphenoidal 
foramen, and foreign body in the orbit. 






MODERN OPHTHALMOLOGY. 


6(>8 


Prognosis in Ocular Paralyses.—This, of course, varies with the cause. 

It is most favorable in the peripheral forms. The tendency to relapse 
must be remembered in connection with those of spinal origin. The dura¬ 
tion of the paralysis is nearly always lengthy, and when treatment fails 
a secondary contracture of the opposing muscle gives rise to a squint, 
which has the effect of equalizing the angle of deviation for all directions 
in which eye is turned, thus practically converting the squint into a comi- 
tant one. 

Paralysis of tiie Seventh Xerye (Facial, or Bell’s, Palsy).— 
When the lesion producing this affection is nuclear, supranuclear, or intra¬ 
nuclear, the upper distribution of the facial nerve (orbicularis palpebrarum ' 
and frontalis muscle) is involved, this involvement is greater and more per¬ 
sistent when the lesion is nuclear, or intranuclear, and in these conditions 
may cause lagophthalmos—an inability to close the lids, which even in sleep 
remain open (Spiller). When associated with paralysis of the trigeminus 
there is danger of ulceration of the cornea supervening, as this membrane 
is then deprived both of its trophic innervation and of its external pro¬ 
tection, and is in consequence easily injured by the foreign matter which 
readilv finds lodgment there. 

Treatment is of the cause, the indications being met in a large per¬ 
centage of cases by the administration of the iodid of potash in ascending 
doses and of mercury used in inunctions, hypodermically, or internally. In 
the later stages strychnin in heroic doses may do good. Electricity, either 
in the form of the constant or the faradic current, is of value. A weak 
constant current of from 1 to 3 milliamperes will be found most serviceable. " 
The negative pole should be applied to the closed lid and the positive one 
to the temple. Mechanical exercise has proven of service. It consists 
in seizing the anesthetized conjunctiva over the insertion of the paralyzed 
muscle and rolling the eye as far as is possible in the direction of the action 
of the muscle. This is to be repeated several times. When, in facial and 
trigeminal palsy, impairment of the cornea is threatened, the operation of 
tarsorrhaphy is indicated. 

Paralytic Mydriasis occurs as the result of lesions affecting the nucleus 
of the third nerve or of the nerve itself. Mydriasis also occurs as the 
result of interruption in the transmission of light-impulses from the 
retina, as, for example, in optic-nerve atrophy; but this is not a true 
paralytic mydriasis. The pupil is partly dilated and is susceptible of 
further dilation by the instillation of a mydriatic. 

The conditions giving rise to paralytic mydriasis are cerebral disease 
(especially general paralysis of the insane), lesions at the base of the brain 
and those involving the nucleus, thrombosis of the cavernous sinus, tabes 
dorsalis (as the result of third-nerve palsy) Orbital disease producing 
pressure on the ciliary nerves, increased intra-ocular pressure (intra-ocular 
growths and glaucoma), blow received upon the globe, diphtheritic and 
ptomain poisoning, apoplectic coma, syphilis, and mydriatics Avhen used 
internally or locally. When paralysis of the iris is associated with paraly- 


ANOMALIES OF THE MUSCULAR APPARATUS. 


6C9 


sis of the ciliary muscle, the condition is known as ophthalmoplegia in¬ 
terna. 

Paralytic Miosis is most frequently met with as a symptom of tabes 
dorsalis and is due to disease of the ciliospinal centre. Later in the course 
of this affection the so-called Argyll Robertson pupil is frequently present 
as a result of the upward extension of the disease process. It is also caused 
by injury to the cervical sympathetic or as the result of pressure upon the 
nerve from aneurism or from enlarged lymphatic glands. 

Paralysis of Accommodation (Cycloplegia).—Paralysis of the ciliary 
muscle is usually associated with involvement of one or more branches of 
the third nerve. Absolute palsy, aside from that induced by cycloplegics, 
is most commonly due to diphtheria. It usually comes on during early 
convalescence, but may be delayed until the sixth week. The symptoms 
are blurred vision and inability to see to do near work, these symptoms 
being especially annoying to hypermetropes. Micropsia is occasionally com¬ 
plained of. Paralysis of accommodation is also met with in diabetes, in¬ 
fluenza, and mumps (Mandonnet). Paresis or weakness of accommodation 
is present in all long and exhausting diseases and as the result of excessive 
venery and masturbation. Unilateral paresis may be caused by syphilis or 
by disease of the teeth. 

The prognosis varies with the cause. Recovery invariably occurs in 
diphtheritic paralysis. Ascending doses of nux vomica and the use of elec¬ 
tricity seem to hasten recovery. 

Spastic Strabismus.—Deviation of the eye due to spasm of one or more 
of the ocular muscles is a rare condition, comprising some cases of inter¬ 
mittent comitant strabismus and of choreic squint. Instances of conjugate 
deviation the result of irritating cerebral lesions, h} T steria, and epilepsy. 

Nystagmus is a condition in which there are short, rapid, rhythmic, 
involuntary movements of the globe. These movements may be horizontal, 
vertical, or rotary, and are nearly always bilateral. Nystagmus is either 
congenital or acquired. The former type is usually associated with de¬ 
fective vision due to optic-nerve degeneration, opacities in the media, patches 
of chorioiditis, and albinism. 

Acquired nystagmus may be symptomatic or occupational. The former 
is frequently a symptom of disseminated sclerosis and of Friedreich’s ataxia, 
and may be due to lesions in the cerebrum or cerebellum. 

Occupational nystagmus is met with in miners engaged in “under¬ 
cutting,” requiring the continuous upward turning of the eyes for long 
periods of time (Snell). The condition has been met with in various 
other occupations and is to be looked upon as being due to fatigue of the 
muscles and exhaustion of their innervation (Baer, Snell). 

Treatment is of avail only in the occupational type, and consists of 
abstinence from work for a time, with absolute rest to the eyes and cor¬ 
rection of existing refraction and muscular errors, or in a complete change 
of occupation. 


670 


MODERN OPHTHALMOLOGY. 


Deviation of the Visual Axes of Non-paralytic Origin (Heterotropia). 

—To this class of muscular anomalies the term comitant strabismus 1 is 
given, because of the distinguishing feature that the angle of deviation re¬ 
mains the same whether the eyeballs are turned in the direction of the 
squint or in the opposite direction; or, in other words, that the affected 
eye follows its fellow fully in all its movements. 

The terms convergent (in), divergent (out), sursumvergent (up), and 
deorsumvergent (down) strabismus are used to distinguish them accord¬ 
ing to the direction assumed by the deviating eye. 

The following nomenclature has been given by Stevens to the condi¬ 
tion of equilibrium and to the various deviations therefrom:— 

Orthophoria, the condition in which muscular equilibrium is maintained with the 
minimum of nervous effort. 

Iteteroplioria, a tending of the visual lines from parallelism. 

Heterotropia, a deviation of the visual lines from parallelism in such a manner that 
they cannot habitually be united at the game point of fixation. 

The class of heterophorias includes:— 

Esophoria, a tending of the visual lines inward. 

Exoplioria, a tending of the visual lines outward. 

Hyperphoria, a tending of the visual lines of one eye in a direction above its fellow. 
(The term is a relative one and must be prefixed by the designating word right 
or left.) 

Intermediate tendencies are termed hyperesophoria (right or left) and hyperexo- 
phoria (right or left). 

Esotropia, a deviation of the visual lines inward. 

Exotropia, a deviation of the visual lines outward. 

Hypertropia, a deviation of one visual line above the other. (The term is a relative 
one and must be prefixed by the designating word right or left.) 

Intermediate deviations are termed hyperesotropia (right or left) and hyper exotropia 
(right or left). 

Variations of the equilibrium, which may or may not be consistent with parallelism 
of the visual lines, but in which, with the least innervation of the eye-muscles, 
the visual lines would tend below or above the most favorable plane for the 
minimum effort, are termed, respectively, catapkoria and anaphoria. 

A rotary tendency, due to insufficiency of the oblique muscles, has been described by 
Savage and has received the name cyclophoria. 

General Symptoms. —Aside from the above characteristic symptom, 
which alone would serve to distinguish this form of squint from the para¬ 
lytic variety, there is usually absence of diplopia, equality of the primary 
and secondary deviations, and amblyopia of the deviating eye by which to 
differentiate them. 

Cause of Heterotropia. —Deviations of the line of vision may have their 
origin in anomalies of refraction, in the structure and insertion of the 
ocular muscles, and in the development of the orbits. 


1 The terms “strabismus” and “squint ” have been retained because of their general employment, 
but the terms introduced by Stevens are to be preferred. 



ANOMALIES OF THE MUSCULAR APPARATUS. 


671 


Comitant Convergent Squint (Esotropia ).—There are three varieties 
recognized: permanent monocular, permanent alternating, and periodic. 

Permanent monocular squint is the most common. It usually makes 
its appearance at the age at which the child first begins to be inter¬ 
ested in near objects, such as toys, picture-books, etc.—about two years 
of age. It may, at first, be periodic, but soon becomes permanent and 
monocular. Its origin is almost invariably attributed by the laity to 
whooping-cough, fright, imitation, or to the attraction of the child’s sight 
to some object hanging overhead. The most frequent, but by no means 
the only cause, is hypermetropic refraction. This operates to produce it 
through the desire for distinct single vision, which can be attained only 
by excessive convergence of the visual axes, with its associated accommoda¬ 
tive act. Normally, for each angle of convergence an equal degree of 
accommodation is employed. In the hypermetrope this balance is dis¬ 
turbed from the beginning, since, in order to see distinctly at a distance, 
the hypermetrope must accommodate to the degree of his hypermetropia and 
still maintain parallelism of the visual axes. Now, when it comes to view¬ 
ing an object at near range, say forty centimetres, one of two conditions 
must prevail: either he must be satisfied with blurred, but single, vision 
(both eyes converged to the object, but accommodation insufficient), or 
he may secure distinct vision (both eyes accommodated for the object, but 
convergence excessive), which will produce double vision unless he per¬ 
mits one eye to turn in, and this is the solution of the difficulty which 
the patient instinctively accepts. Other causes of convergent squint are: 

1. Congenital weakness of the external rectus muscles, which would 
be particularly apt to produce convergent squint if from any cause one 
eye is amblyopic, or the retinal image is distorted or faint as the result 
of opacities in the cornea or other of the refractive media. 

2. A high positive quality of the angle gamma would tend to the 
production of a convergent squint. 

3. Failure of development of the fusion centre (Worth). 

In convergent squint the result of hypermetropia, the deviating eye. in 
more than half the cases, is found to be amblyopic. The causal relationship 
between the squint and the amblyopia still remains in dispute, some authori¬ 
ties looking upon the amblyopia as the result of the squint from disuse ol 
the eye, and others regarding it as the cause of the squint by removing the 
stimulus to convergence which would be excited if there was a tendency to 
diplopia. The absence of diplopia in comitant strabismus may be due to the 
suppression of the retinal image, or it may arise from the development 
of new identical points in the retina of the deviating eye. 

Comitant Divergent Strabismus (Exotropia ).—The same varieties of 
this form of squint may be recognized as of convergent strabismus. r l he 
permanent monocular variety is the most common, but the alternating is 
more frequent than in convergent squint. As a rule, divergent squint 
appears later in life than does convergent, because it is usually associated 


G72 


MODERN OPHTHALMOLOGY. 


with high degrees of myopia, which-condition, for the most part, is an 
acquired anomaly. It is also seen as a sequel to insufficiency of con¬ 
vergence—a condition which may be met with in any state of refraction. 
Excessive divergence of the axes of the orbit in the course of the develop¬ 
ment of the skull may lead to divergent strabismus (Weiss). Diplopia 
is of more frequent occurrence than in convergent squint, probably because 
binocular vision has been maintained to a later period of life. The angle 
of squint is the angle which the visual axis of the deviating eye forms 
with the direction which it should have in a normal condition (Landolt). 


A 



Fig. 377.—Measurement of the angle of squint by the perimeter. 

D, Squinting eye. S, Fixing eye. 0, Observer’s eye. L-M-F, Angle of squint. C, C, Centre 

of corneas. 

Determination of the Angle of Squint.— Much ingenuity has been 
displayed in devising methods for the ready estimation of the angle of 
squint, and of these methods three will be detailed—those by the perimeter, 
by prisms, and by the linear method, or strabismometry. 

By the Perimeter .—The patient is seated before the perimeter, with 
both eyes uncovered, and is directed to look at the button on the perimeter or 
at a candleflame held on the visual line at a greater distance. While so doing 
a second lighted candle is carried along the arc of the perimeter, and the 
examiner, with his eye placed directly behind this candleflame, notes when 
the image of the flame falls upon the centre of the cornea of the deviating 
eye, and when this has come to pass the angle of the squint may be read 





ANOMALIES OF THE MUSCULAR APPARATUS. 


G73 


off in degrees. The centre of the cornea is employed because it is im¬ 
possible to determine the visual axis by this method; consequently the 
result obtained is only approximately correct, as it does not take into con¬ 
sideration the difference which almost invariably exists between the optic 
axis and the visual axis and the resulting angle formed by the crossing of 
these two lines at the principal optical centre. In order to be exact, this 
angle must also be estimated and its value added in convergent squint and 
deducted in divergent squint from the angular determination. 

By Prisms .—This method is applicable only where diplopia exists 
spontaneously or can be induced. When diplopia does not exist spon¬ 
taneously, which is the rule, it may sometimes be induced by placing a 
red glass before the eye with the better vision; this failing, a prism should 
be placed vertically before one eye, and, by thus throwing the image on to 
a different part of the retina, diplopia may often be excited. Prisms are 
to be held horizontally before either eye of sufficient strength to fuse the 
two images if diplopia be induced by the first method, or until the images 
stand one above the other, if diplopia be induced by the second method. 



Fig. 37S.—Linear measurement of squint. 


A second method of employing prisms to measure the degree of devia¬ 
tion is in connection with the cover test. That prism is a measure of the 
squint which maintains the visual axes directed to the fixing object held 
about forty centimetres before the eye when the cover is transferred from 
one eye to the other. 

Linear Method .—A ruler is held close against the lower lid of the 
squinting eye, and the divisions corresponding to the centre of the cornea 
when the eye is made to fix a distant object, and when it again is allowed 
to assume its abnormal position, are noted. The difference is a measure of 
the squint. A special instrument called a strabismometer may be used. 
This test is not without value in determining the length of the piece of 
muscle desirable to remove in performing advancement with resection of 
the muscle in high degrees of squint, but, as is insisted upon by Landolt, 
it is manifestly incorrect to speak in linear terms of an angular quantity. 

Treatment of Strabismus. —The vast majority of cases of strabismus 
having their origin in an error of refraction, the first step in their treat¬ 
ment will consist in the correction of that error. The total anomaly should 


43 






674 


MODERN OPHTHALMOLOGY. 


be determined under complete paralysis of the ciliary muscle, secured 
preferably by the use of atropin, and the glass which is found to correct it 
should be worn constantly. By the aid of ophthalmoscopy and retinoscopy 
the refraction status can be quite accurately determined, even in very young 
children, and at the age of three and a half 3 'ears they may be given glasses 
to wear. Experience has demonstrated that, by this method of treatment, 
the visual axes are rendered parallel in cases of moderate degree. The 
parallelism is maintained so long as the glasses are worn, the eye reverting 
to its faulty position as soon as they are removed. In cases where con¬ 
vergent squint manifests itself before the age at which it would be deemed 
advisable to place spectacles on the child, a course of atropinization for 
the purpose of relaxing the convergence by paralyzing the accommodation 
should be employed. A weak solution of atropin (gr. j to gj) should be 
instilled into the fixing eye twice daily for a period of several months, care 
being taken not to get the toxic effect of the drug and to shade the eyes 
from bright light. In a few cases the primary effect of the atropin will be 
found to increase the squint as the result of the excessive accommodation 
innervation which is induced by the attempts of the patient to see dis¬ 
tinctly (Savage). 

Orthoptic Treatment .—For success with this method diplopia must 
exist; and, if not present spontaneously, it must be induced. This condi¬ 
tion obtaining, a stereoscope, in which the prisms have been replaced by 
convex spheric lenses of 6 I). strength, and in which the distance between the 
stereoscopic pictures for the two eyes may be increased or lessened at pleas¬ 
ure, is employed to stimulate binocular vision. The test pictures must be 
placed at the focus of the lenses so that they will be plainly seen without 
accommodation, and, associated convergence being stimulated,—if the 
visual axes be parallel, and the pictures be not too far apart,—the two images 
will be fused into one having the third dimension. Where the visual axes 
converge, the pictures must be approximated until both eves see simul¬ 
taneously. After this has been accomplished actual fusion and restoration 
of binocular vision may be expected. Where there is unequal acuity of 
vision in the two eyes, difficulty will be experienced in inducing the eye 
with the reduced visual acuity to perceive the picture corresponding to that 
eye. Equalizing the visual acuity of the two eyes by fogging the sight of 
the better-seeing eye, by using a higher plus lens than is before the other 
eye, or repeatedly and momentarily excluding the better eye, will be found 
of assistance. The amblyoscope of Worth also will prove useful in develop¬ 
ing the vision of amblyopic eyes and in bringing about binocular vision 
if employed during the years the fusion faculty is developing—that is, 
before the child is six years of age. The patience and time required to 
secure results, and the limited field of usefulness of this form of treatment, 
have interfered with its securing the position it deserves. It will also be 
found of service in restoring binocular vision where operation has produced 
spontaneous diplopia. 


ANOMALIES OF THE MUSCULAR APPARATUS. 


675 


Operative Correction of Strabismus. —Should the above methods fail 
to restore parallelism to the visual axes, the question of operative interven¬ 
tion must be considered. No unanimity exists among surgeons, either as 
to the method to be pursued or as to the age at which it should be under¬ 
taken. \\ ithout entering into a discussion of the reasons it may be stated 
that the operation of advancement of the tendon of the muscle more nearly 
restores the normal physiologic and anatomic relations than does tenotomy. 
However, owing to the ease with which it may be performed, tenotomy is the 
prevailing method of procedure. No operation should be performed until 
the patient has arrived at an age at which a comprehensive study of the 
conditions can be made and the co-operation of the patient can be obtained 
in restoring binocular vision. Nor should it be delayed until time has 
effaced the memory of binocular vision. As to the results to be expected 
from the performance of tenotomy, it may be stated for general guidance 
that a tenotomy of a single internal rectus muscle, without a free dissection 
of the reflected fibres of the capsule of Tenon, will correct about 15 to 20 




Balance for 
vertical 
muscles. 



Balance for 
horizontal 
muscles. 



Right 

hyperphoria. 




Left Exophoria. 

hyperphoria. 


A 

Esophoria. 


Fig. 379.—Relative positions of the line of light and the candle-flame in the 

Maddox rod test. 


The rod is before the right eye. 


degrees of deviation; and a double tenotomy, from 20 to 35 degrees. The 
effect will be somewhat less after the same operation on the external mus¬ 
cles. For higher defects a tenotomy with advancement of one or both of 
the opposing muscles may be required. 

Latent Deviation (Heterophoria). —So great is the antipathy to double 
vision that a weakness of a muscle of sufficient degree to become at once 
manifest, when the incentive to binocular vision has been removed, will be 
continuously overcome, but at the expense of exhausting nervous innerva¬ 
tion. 

The muscular equilibrium may be disturbed by either an actual or a 
relative weakness of one or more muscles, such weakness causing a tendency 
toward deviation of the visual axes. 

For the determination of these tendencies it is necessary to remove the 
incentive to binocular vision. Various methods for accomplishing this 
have been devised, but only the more useful will be considered. 

Maddox Rod Test. —A cylinder of glass, or some modification thereof, 
which has the effect of converting the image of a point of light into a 























616 


MODERN OPHTHALMOLOGY. 


line of light having a direction at right angles to the long axes of the cylin¬ 
der is placed before the eye, with its length horizontal, if it be desired to 
test the lateral muscles, and vertical if the vertical muscles are to be tested. 
A small light is placed at a distance of five metres in front of the patient. 
The line of light replaces, in the eye before which the rod is placed, the 
image of the flame. If the visual axes be parallel, the line of light will 
bisect the flame. If exophoria exist, the line of light will lie to the opposite 
side of the flame to that of the eye before which the rod has been placed 
(crossed diplopia). In esophoria it will lie on the side corresponding to the 
eye before which the rod has been placed (homonymous diplopia). In 
hyperphoria it will lie above or below the light, and will be designated right 
or left according to whether the image of the right or left eye be the lower. 

Equilibrium Test (von Graefe's Test). —A prism of 8° or 10° is 
placed with the base down before either eye and a small light at twenty feet 
(six metres) distance is used as the test-object. The prism removes the 
tendency to fusion by displacing the image belonging to the eye before 
which the prism has been placed to a point below the fovea, in consequence 
of which it will be projected above the image belonging to the other eye. If 
orthophoria for the lateral muscles exists, the images of the two eyes will 
stand one directly above the other. If exophoria be present, the displaced 
image will lie to the opposite side of the image belonging to the other eye 
from that before which the prism has been placed. If esophoria be present, 
it will lie on the corresponding side. 

To prevent fusion of the images in testing the balance of the vertical 
muscles, a somewhat stronger prism should be employed with the base of 
the prism held toward the nose. If hyperphoria exists, one light will ap¬ 
pear higher than the other. Hyperphoria of that eye exists whose image 
is the lower. In all these tests the degrees of the prism required to bring 
the lights into alignment is a measure of the deviation. The equilibrium 
test is now usually made with the phorometer of Stevens, which consists 
of a pair of 5° prisms so mounted, in rotary cells, one before each eye, that 
their bases are opposed when the prisms are rotated to the vertical position 
and are in apposition when in the horizontal position. A scale is so affixed 
to the circumference of each cell that the amount of heterophoria, 
which is determined by the amount of rotation requisite to bring the 
lights into alignment, may be at once read off. Accessory cells in which 
are mounted a rotary prism and a Maddox rod and which contain grooves 
for trial lenses complete an instrument which is suited for testing the refrac¬ 
tion and muscular anomalies. 

Parallax Test (Duane). —While fixing a small light placed at a dis¬ 
tance of twenty feet (six metres), and as close to the plane of the wall as is 
possible, one eye is momentarily covered by a card, after which it is rapidly 
transferred to the other eye. If heterophoria exists, an apparent movement 
of the light will take place. If this movement takes place in the direction 
of the eye to which the card is transferred, exophoria is present ; if in the 


ANOMALIES OF THE MUSCULAR APPARATUS. 


677 


opposite direction, esoplioria exists. If the movement is up, there is hyper¬ 
phoria, designated by the side to which the card has been transferred; 
if down, there is hyperphoria, designated by the side from which the card 
has been transferred. The degree of the prism which neutralizes the 
apparent movement is a measure of the deviation. 

Cobalt-Glass Test. —This simple test will be found to uncover even 
very low degrees of heterophoria. A cobalt glass or the superposed red and 
the blue glass usually found in trial cases is placed before one eye, and in 
front of this is held a card. After waiting twenty or thirty seconds the 
card is slowly withdrawn laterally from in front of the pupillary space; 
and when the edge of the card has passed the visual axis two lights—one of 
a cobalt color, the other of the color of the flame—will be observed, if 
heterophoria exist. If orthophoria is present, but one light of the color re¬ 
sulting from the superposition of the two images will be seen. That prism 
or combination of prisms with which but one light is observed is a measure 
of the degree of heterophoria. 

In all of the above tests the test-object should by preference be a 
luminous disc from one-half to one centimetre in diameter. 

The above tests serve to indicate the tendency of the visual axes when 
the accommodation is at rest. To determine this tendency when it is being 
used—that is, at reading distance—either of the first two tests may be 
employed, using for the test-object a three-millimetre dot on a white card, 
and a 30 D. convex cylmdric lens in place of a Maddox rod. 

Cover Test. —One eye is covered by the hand of the examiner while 
the other fixes a pencil-point held in front of the face at a distance of forty 
centimetres. After a few moments the hand is transferred to the other 
eye, when, if heterophoria exists, the uncovered eye will be seen to make a 
movement in order to fix the pencil-point. If the eye moves outward, it 
must have been deviated inward while under cover, indicating insufficiency 
of the external rectus, or esophoria. If it moves inward, it must have been 
deviated outward while under cover, indicating exophoria. If it moves 
either upward or downward, it indicates hyperphoria. If no movement 
takes place, the visual axis must have maintained the same direction as that 
of the other eye, indicating orthophoria. 

Test for Cyclopiioria (Savage).—A Maddox double prism is placed 
before one eve with the basal line bisecting the pupillary space, horizontally, 
the other eye being covered. The patient is directed to look at a horizontal 
line drawn on a card, held at forty centimetres. The effect of the prism is to 
produce monocular diplopia, two parallel horizontal lines appearing. The 
other eye is now uncovered, when a third line, placed between the other 
two, will come into view. The naked eye is the eye under test. If there 
is harmonious action of the oblique muscles, the three lines will appear 
parallel. If there is want of harmony, it will be shown by obliquity of the 
middle line. With the prism before the right eye, if the right end of this 
line dips, there is insufficiency of the left superior oblique; if the left end 


GTS 


MODERN OPHTHALMOLOGY. 


dips, there is insufficiency of the left inferior oblique. With the prism be¬ 
fore the left eye, if the left end dips, there is insufficiency of the right 
superior oblique; if the right end of the line dips, there is insufficiency of 
the right inferior oblique. 

Having determined the direction assumed by the visual axes when 
deprived of the extra innervation called forth by the desire for single vision, 
it remains to determine whether this abnormal tendency is associated with 
deficient or excessive adducting or convergence power; deficient or excessive 
abducting or divergence power; or deficient or excessive supra- or infra¬ 
ducting power. 

The power of convergence can be measured in metre angles (see page 
123) or by determining the near point of convergence, and also by the 
power of the internal recti muscles to overcome the diplopia produced at 
twenty feet (six metres) by prisms placed with the bases out before the 
eyes. In order to estimate the near point of convergence it is only necessary 
to approach a pointed lead-pencil to the eyes along the median line and 
measure the distance from the eyes at which the point begins to appear 


A. 


B. 


C. 


D. 


Fig. 3S0. 

A, Insufficiency of the left superior oblique. B, Insufficiency of the right superior oblique. C, In¬ 
sufficiency of the left inferior oblique. D, Insufficiency of the right inferior oblique. 


double. Prism convergence varies greatly within normal limits, ranging 
from 25 to 90 degrees or even more. 

The power of divergence can be measured only by the power of the ex¬ 
ternal recti muscles to overcome or fuse the diplopia produced by prisms 
held with the bases in before the eyes. This normally equals from T to 8 
degrees. 

It will he found that the adducting power determined at the first 
trial is frequently very far below the above-mentioned limits even in those 
with whom a few trials develop a normal degree or who possess the full num¬ 
ber of metre angles of convergence, while the abducting power is a fairly 
constant quantity in repeated tests. Supraduction is measured by the degree 
prism which, placed with its base down before either eye, can be overcome; 
likewise infraduction is measured by the degree prism which can be over¬ 
come when placed with its base up before either eye. Both should equal 
2 to 3 degrees. 

The following is, in abstract, Duanfe’s finding of associated conditions 
in excessive and insufficient convergence and divergence power:—■ 


















ANOMALIES OF THE MUSCULAR APPARATUS. 


679 


In Insufficiency of Convergence there is either orthophoria or a tend¬ 
ency to exophoria at twenty feet (six metres) and marked exophoria at near 
distances. The near point of convergence may be seven to ten centimetres. 
The adducting power is low and difficult to develop, and the abducting 
power is normal, slightly increased, or decreased. 

In Excessive Divergence there is exophoria for near and far distances. 
The convergence near point is nearly normal. The adducting power is low 
or may be normal and the abducting power is excessive. 

In Insufficiency of Divergence there is esophoria for distance and 
orthophoria or possible exophoria for near. The convergence near point is 
normal. The adducting power is normal and the abducting power is greatly 
diminished. 

In Excessive Convergence there is orthophoria or slight esophoria for 
distance and marked esophoria for near. The near point of convergence is 
very close to the eyes. The adducting power is high and the abducting 
power may be low. Disturbance of vertical equilibrium affects the lateral 
equilibrium and may aggravate or even originate lateral deviations. 

Symptomatology. —Disturbance of the ocular muscular equilibrium 
gives rise to a great variety of symptoms, ranging from ocular pain with 
headache to a symptom-complex simulating grave organic nervous disease. 
The more usual group of symptoms is headache, basal or extending from the 
eyes to the occiput; pain between the shoulder-blades; confused vision fre¬ 
quently called forth by car-riding, sight-seeing, and shopping, and often 
causing anxiety in the turmoil of crowded thoroughfares; consciousness 
on the part of the patient that the ocular muscles are not working in har¬ 
mony (in some instances the patient will state that the sensation is as though 
he had lost control of the eyes and that they had momentarily turned 
either in or out); nausea and dizziness and even vomiting if the strain is 
continued. Eestlessness is frequently marked, especially in children. 
There can be no doubt that neurasthenia does result from uncorrected 
muscular anomalies, and it is conceivable that epilepsy, migraine, and 
chorea might be induced in the extremely neurotic with strong predisposi¬ 
tion to these affections. The local symptoms do not differ greatly from 
those excited by anomalies of the refractive media, namely: blepharitis, 
clonic blepharospasm, hordeola, and congested conjunctiva, at times more 
pronounced over the insertion of the faulty muscle. 

Treatment. —The first measure to be adopted, in the treatment of 
these troublesome disturbances, is fully to correct any error of refraction 
that may exist, the only exceptions to this rule being those cases of in¬ 
sufficiency of convergence associated with hypermetropia, where it is advis¬ 
able to stimulate convergence through the accommodation, which may in a 
measure be accomplished by correcting only so much of the hypermetropia 
as is consistent with the age of the patient and the work required of the 
eyes; and in those cases of myopia associated with divergence insufficiency, 
where convergence should be lessened by diminishing the accommodation, 
which may be accomplished by partially correcting the myopia. 


680 


MODERN OPHTHALMOLOGY. 


In connection with the local treatment general treatment is always 
demanded. Many of these sufferers are the offspring of neurotic parents 
or come of phthisical stock. The use of nux vomica for insufficiency' of 
convergence and of hyoscyamus for insufficiency of divergence will be found 
to he of only temporary benefit. 

The symptoms excited by low degrees of heterophoria are often allayed 
by the wearing of prisms. This is particularly true of vertical tendencies, 
and, in cases where this is of moderate degree, about two-thirds of the whole 
amount may be corrected with the expectation of thus unmasking some of 
the latent rror. When this occurs it should again be corrected, and this 
procedure can be repeated until the error is a constant one, when an opera¬ 
tion can, with understanding, be performed. 

In iveak adduction it is well not to correct the total amount of exo- 
phoria, as it is apt still further to increase the convergence insufficiency. 
Usually the prisms need be worn only at near work, and for this purpose 
they may be put into fronts, a supplementary frame to be hooked on the 
front of the spectacles containing the refraction correction. Esophoria 
may be totally corrected in weak abduction. There are optical and physical 
limits to the degree possible to be corrected by prisms, and, as a rule, 3.5° 
prisms before each eye is about all that can be worn, and these are apt to 
be uncomfortable, owing to their weight, to the chromatic aberration, and 
to the reflection from their surfaces. 

Several methods have been proposed for strengthening adduction and 
adduction. The plan most in vogue is to practice fusing of images pro¬ 
duced by placing prisms before the eye in such a manner that the false image 
is displaced in the direction of action of the muscles to be strengthened. A 
small flame having been placed at a distance of six metres, the patient is 
directed to begin with the weakest prism which produces diplopia and en¬ 
deavor to fuse the images. When this has been accomplished the eyes are 
to be momentarily closed, and, as soon as on opening the eves fusion occurs 
without conscious effort, the strength of the prism is to be increased. Ex¬ 
ercise of convergence or adduction requires the use of prisms placed with 
their bases toward the temple. Care must be taken to have the prism 
exactly horizontal, which may be told by the lights being on a horizontal 
line, or fusion will be difficult or even impossible. Such exercise should 
not be continued longer than ten minutes at a time nor repeated oftener than 
twice a day. When adduction has reached about 50 degrees no further in¬ 
crease is necessary, but prisms of this strength should be practiced with 
thereafter. In order to exercise divergence or abduction, the weakest prism 
which produces diplopia at six metres should be placed before the eye. If 
fusion is impossible the light should be approached, and, when the images 
merge, the distance from the light should be increased. A divergence power 
of 8 degrees should be striven for. Adduction may also be strengthened by 
having the patient view the tip of a pencil as it is approached to the eyes. 
As soon as it appears double he should look momentarily at a distant light; 


ANOMALIES OF THE MUSCULAR APPARATUS. 


681 


this is to bo repeated for about ten minutes, twice a day. Should all such 
means fail to correct the deviation or to relieve the subjective symptoms, 
operative intervention is called for. 

Savage seeks to exercise the weal ; obliques by the use of cylindric lenses 
placed at oblique axes before the eyes. Either convex or concave lenses 
may be employed. If convex, the axes must be placed in the lower temporal 
quadrant for insufficiency of the superior obliques, and in the lower nasal 
quadrants for insufficiency of the inferior obliques. The effect is increased 
by revolving them from the vertical, the maximum effect being secured at 
45 degrees therefrom. The exercise should be commenced w r itli 0.50 D. 
lens placed before both eyes, and increased each day a 0.50 D. up to 3 D. 
The patient is directed to fix a distant light for three minutes, at the end 
of which time the cylinders are revolved symmetrically 15 degrees and the 
light is again viewed. The exercise may be repeated twice a day. 

In convergence weakness the proper operation is advancement of the 
tendon of the internal rectus muscle or advancement of the capsule of 
Tenon. The latter operation w r ill be found useful where the exophoria does 
not exceed 8 degrees for near. 

In convergence excess a carefully performed tenotomy of the internal 
rectus is called for. 

In divergence weakness, advancement of the tendon of the external rec¬ 
tus or of the capsule of Tenon is the proper procedure. 

In divergence excess a carefully performed tenotomy of the external 
rectus will be found adequate. 

OPERATIONS ON THE OCULAR MUSCLES. 

Tenotomy.—General anesthesia is required only in patients under eight 
years of age. For local anesthesia a 4-per-cent, solution of cocain will 
be found efficient, a few drops being instilled into the conjunctival sac 
before the operation and into the subconjunctival tissues through the con¬ 
junctival incision from time to time during the operation. A stop specu¬ 
lum having been inserted, the conjunctiva is incised with a pair of tenotomy 
scissors a little to the corneal side of the insertion of the tendon. The 
underlying fibres of the capsule of Tenon are then snipped sufficiently to 
expose the insertion of the tendon and so permit of the strabismus-hook 
being inserted beneath the tendon. The tendon is then severed by a series 
of cuts made with the scissors between the hook and the globe. To make 
sure that no strands have been left undivided the hook should be reinserted 
and, with its point kept in contact with the sclera, it should be sw r ept above 
and below the limits of the attachment. If a thorough division has been 
made, the hook will appear subconjunctivally at the margin of the cornea. 
A conjunctival suture is unnecessary. Panas advises stretching of the mus¬ 
cle before severing it. The eye should be lightly bandaged for about forty- 
eight hours. Immediately after the operation the excursions of the eyeball 
should be full, and, if the internal rectus has been cut, convergence to five 


682 


MODERN OPHTHALMOLOGY. 


centimetres should be possible; if it is not, then the muscle should be 
brought forward by a suture, one end of which passes through the tendon, 
the other through the conjunctiva close to the cornea. The hemorrhage 
attending this and other operations made on the ocular muscles will be 
much lessened by the use of a few drops of adrenalin solution (1 to 3000). 

Accidents. — 1 . Perforation of the Sclera during the operation of 
tenotomy has occurred to many distinguished operators, but such an acci¬ 
dent is usually due either to want of skill or to the use of sharp-pointed 
instead of blunt scissors. The accident is announced bv a sinking back of 
the iris, a loss of vitreous humor, and a reduction in ocular tension. If 
the accident occurs before the tendon has been severed, it should be cut, 
provided the wound is anterior to the tendinous attachment, since the con¬ 
traction of the undivided muscle will cause the wound to gape. If the 
wound is posterior to the attachment, the muscle should not be cut, since 



Fig. 381.—Tenotomy of the external rectus muscle. (Author.) 

(Original drawing by Dr. K. W. Mills.) 

its normal action will tend to keep the lips of the wound coaptated (Ris- 
ley). The conjunctiva should be sutured, both eyes should be bandaged, 
and the patient should be placed in bed. Under favorable circumstances 
healing will occur without sequelae. Some of the reported cases have been 
followed by severe pain, ciliary staphyloma, chorioidal atrophy, reduction 
in visual acuity, and even panophthalmitis. 

2. Excessive Hemorrhage may occur, particularly in hemophiles. It 
may come from cutting too deeply into the orbital tissues, causing Tenon's 
capsule to fill with blood and the eye to protrude. Masses of fat sometimes 
appear in the wound and should be excised. The conjunctiva should be 
sutured and a pressure bandage should be applied. 

3. Post-operative Infection occurs in rare instances, and may lead to 
tenonitis, panophthalmitis, orbital phlegmon with atrophy of the optic 
nerve, atrophia bulbi, etc. The condition will require appropriate treat- 




ANOMALIES OF THE MUSCULAR APPARATUS. 


683 


ment. A case of diphtheritic infection in the tenotomy wound, occurring 
in Knapp’s practice, ended in panophthalmitis. 

Jf.. Unpleasant Sequelae of tenotomy have been frequently observed. 
Among them are sinking of the caruncle, exophthalmos, and the conversion 
of a convergent into a divergent squint. 

5. Operation upon the Wrong Eye must be avoided. 

Graduated Tenotomy.—The operation of graduated tenotomy has been 
practiced now for many } T ears, but the question of its value still remains 
a subject of dispute. The topographic relations existing between the mus¬ 
cles of the eyeball and the eyeball itself: the small result sometimes ob¬ 
tained from a complete division of a tendon; and the slight—at times 
negative—effect upon muscular anomalies where the graduated operation 
has been repeatedly performed, all are calculated to inspire distrust in its 
efficacy. 

In those exceptional cases where attention to the error of refraction, to 
the development of the ducting power of the muscles, and to the health of 



Fio 1 382.—Advancement of an ocular muscle, showing the suture in 

O 

position before tying. 

the patient fail to remove undoubted reflex symptoms, it will usually be 
found that there exists a latent phoria which finally, under prismatic cor¬ 
rection of the manifest degree, becomes total and suited to a thorough 
surgical procedure. 

Operation. —For this operation special instruments, more delicate in 
construction than those used for complete tenotomy, have been devised by 
Stevens. A small fold of conjunctiva, directly over the insertion of the 
tendon, is seized and snipped transversely so as to make a minute opening. 
Into this opening the forceps are introduced and a small fold of the tendon, 
immediately behind its insertion into the sclera, is grasped and snipped. 
One blade of the scissors is introduced into the opening thus made, and is 
slipped beneath the tendon, which is then snipped in the direction of one 
of its borders, to such an extent as may be deemed necessary. The scissors 
are then turned in the direction of the opposite border, and an equal extent 
of the tendon is divided. The effect of the operation is then determined, 
and, if insufficient, more of the tendon is divided. This procedure is re¬ 
peated until orthophoria is produced. 










6S4 


MODERN OPHTHALMOLOGY. 


Advancement.—This operation is severe and tedious, and will be much 
better done if performed under general anesthesia. A stop speculum is 
inserted and Tenon’s capsule is exposed by a large conjunctival incision, 
after which it is incised freely over the insertion of the muscle and particu¬ 
larly at the borders, so that the muscle can be lifted from the sclera. One 
blade of an advancement forceps is then slipped beneath the full width of 
the tendon and sufficiently far back to permit, if necessary, of excision of a 
piece of the muscle in advance of its blades, and the forceps closed; if 
tenotomy of the opposing muscle is called for, it is well to do it at this 
stage. The tendon is now severed and one needle of a double-armed black 



Fig. 383.—Total advancement. (Author.) 

(Original drawing by Dit. R. W. Mills.) 

In this operation the muscle, capsule of Tenon, and conjunctiva all are advanced. The tissues 
external to the dotted line are to be excised. 


suture is entered from beneath the tendon and as close to its lower border 
as is possible. It is then interwoven into the muscle parallel to its cut edge 
and is brought out as close as is possible to the upper edge of the tendon. 
The upper needle is then inserted into the episcleral and conjunctival tis¬ 
sues at a distance of about five millimetres above, and the lower needle the 
same distance below, the horizontal meridian of the cornea, and the ends 
of the sutures are tied. While tying the sutures the eyeball should be 
rotated in the direction of the severed muscle. The conjunctival wound 
should be sutured, redundant tissue having been first excised. The imme¬ 
diate result should be a marked squint of an opposite nature to that for 
which the operation was done. 







ANOMALIES OF THE MUSCULAR APPARATUS. 


685 


Capsular Advancement.—General anesthesia is not necessary. I lie 
stop speculum having been introduced, the capsule of Tenon is laid baie by 
a large conjunctival incision. It is then buttonholed at the lower margin 
of the tendon at its insertion. A strabismus-hook is inserted into the 
opening, passed beneath the muscle, and brought out at the upper border 
of the tendon by incising the overlying capsule. The conjunctiva is then 
dissected up to the cornea and nearly as far as the vertical meridian. A 
needle, threaded with a black silk suture, is passed through the episcleral 
tissue at a point as far back almost as the lower end of the vertical meridian 
of the cornea, and is brought out into the conjunctival opening, where it 
is grasped and inserted into the opening previously made into the capsule, 
under which it is passed as far as the result required warrants, and is there 
made to emerge through the overlying conjunctiva. After a similar suture 
has been inserted at the upper margin of the muscle the two ends of each are 
tied. The immediate effect should be a marked overcorrection of the devia¬ 



tion. In the advancement operations it is well to bandage both eyes and 
keep the patient abed for forty-eight hours. Ice may be applied for the 
first twelve hours. The stitches should be removed in five or six days. 

[Fox’s Capsular Advancement for Divergent Strabismus. Ibis opeia- 
tion. which is done under cocain anesthesia, consists of three steps: (1) 
tenotomy of both external recti muscles and stretching of the conjunctiva 
and of Tenon’s capsule; (2) the making of an elliptical opening through 
the conjunctiva and capsule, either on one or both sides; (3) the suturing. 

1 Tenotomy of both external recti muscles is performed m the ordi¬ 
nary manner. Tenon’s capsule is then stretched by means of traction made 
upon it with strabismus-hooks. 2. With the retractor forceps (Fig. 384) 
the conjunctiva is grasped vertically at a point midway between the cornea 
and caruncle, directly over the internal rectus muscle. That part of the 
conjunctiva which is grasped by the instrument, together with the subjacent 
part of Tenon’s capsule, is excised. 3. Excision of these tissues leaves a 
gaping wound. This is to be closed with sutures, which are to be passed 
through the conjunctiva and capsule of Tenon. Ball.] 





CHAPTER XXL 


ERRORS OF REFRACTION. 

By JOHN T. KRALL, M.D., of Philadelphia, 

Assistant Surgeon to the Wills Eye Hospital anrl Dispensary ; Ophthalmic Surgeon to 

the Presbyterian Hospital. 

PROPERTIES OF OPTICAL LENSES. 

In order more fully to understand the errors of refraction and their 
treatment we will briefly consider the properties of optical lenses. 

Light may be described as that form of radiant energy which may be 
appreciated by the organ of sight. Not all light-waves are capable of affect- 



Fig. 3S5.—Passage of an oblique ray from a rare to a dense medium. 

- S-S, Plane surface separating the media, the rare medium being above. A, Luminous 
point. P-P, Perpendicular, g, Angle of incidence. E-D, Sine of the angle of incidence. 
G-II, Sine of the angle of refraction, i, Angle of refraction. 


ing the sight. Light-waves travel through vacuum at the rate of 186,380 
miles per second. They do not travel with the same velocity through all 
substances; the speed is less in water than in air, and is still less in glass. 
When a ray of light passes from a rarer to a denser medium it will meet 
increased resistance, which retards its progress. If the transmitting body 
is less dense than the surrounding media, the vibrations will meet with less 
resistance; hence they will move with greater velocity. The denser the 
body, the greater the length of time required to penetrate. The relative 
length of time it takes light to travel a certain distance in a given sub- 
( 686 ) 
































ERRORS OF REFRACTION. 


687 


stance is called the index of refraction of the substance. If a rav of light 
enters a new medium in a direction perpendicular to its surface, all parts 
of the wave-front will he retarded simultaneously and no change in direc¬ 
tion will occur. If the wave-front strikes the surface obliquely, one por¬ 
tion still moving in the first medium and retaining its original velocity, 
while another part of the same wave-front has passed into the second 
medium, its velocity is impeded, and as a result the wave-front assumes a 
new direction. This change in direction is called the refraction of light 
(Fig. 385). 



Fig. 3S6—Refraction by plane glass. 

Rays of light passing from a denser into a rarer medium are deviated 
from the perpendicular. Should the transmitting medium be rarer than 
the surrounding medium, rays of light will be turned away from the per¬ 
pendicular. The deviation depends upon the mediums and the angle of 
incidence (g in Fig. 385). The greater the angle of incidence, the greater the 
deviation. The deviation diminishes as the angle of incidence diminishes. 
The index of refraction is obtained by dividing the sine of the angle of 
incidence (E-D in Fig. 385) by the sine of the angle of refraction (G-H in 
Fio- 385). If a plate of glass with parallel surfaces be held in the air, and 



Fig. 387.—Refraction by a prism. 


a ray of li-ht be allowed to fall obliquely upon it (Fig. 386), no deviation 
will occur "as the angle of refraction at the second surface will be equal to 
the angle'of incidence at the first surface; but if the surfaces instead of 
Lein- parallel were inclined toward one another, as in a prism (Fig. 387), 
that part of the wave-front that goes through the thicker part of the prism, 
the base will he more retarded than the part that goes through the thinner 
part of the prism, the apex; consequently it would be turned toward the 
bise of the prism.' The amount of deviation between the directions of the 
incident ray and that of the refracted ray is called the angle of deviation. 








G88 


MODERN OPHTHALMOLOGY. 


And the amount of angular separation of the two refracting surfaces is known 
as the refracting angle. The amount of deviation produced by a prism 
varies with the angle at which the incident ray strikes it. 

Prisms are numbered by either one of two systems. The ccntrad 
was introduced by Dennett. It consists in measuring upon a radian the 
amount of linear deflection given to a ray of light which has entered any 
prism at right angles to its refracting surface, this radian being an arc 
of a circle which is equal to the radius. A prism which will produce an 
angular deviation of the one-hundredth part of this arc is called one 
centrad. The grism-clioptre was suggested bv Prentice. The unit is rep¬ 
resented by a linear deflection which is equal to the one-hundredth part 
of the radius measured on the tangent. A prism situated at one metre’s 
distance from a definite tangent plane and deflecting a ray of light one 
centimetre along that plane is called a prism-dioptre. 

If two prisms are placed with their bases together as in A, Fig. 388, we 
then have the fundamental principle of a converging, or convex, lens. If 

A B 




Fig. 388.—Refraction by prisms. 

the prisms are reversed and placed apex to apex, as in B, Fig. 3S8, a dis¬ 
persing, or concave, lens is formed. A convex lens is simply a series of 
prisms with bases together; and a concave lens is a series of prisms with 
their apexes together. 

A lens may be defined as any transparent medium bounded by surfaces 
of which at least one is curved. There are six general classes of lenses, as 
illustrated in Fig. 389. 

A meniscus, or periscopic lens, is represented in C and F (Fig. 389). 

A line drawn through the centre of curvature of a lens is called its 
principal axis. Pays which do not pass through the optical centre are 
known as secondary axes. 

The optical centre is a point situated on the principal axis within the 
lens-substance, except in a meniscus, where it is external. It is found by 
taking two parallel radii of curvature and connecting the points in which 
they meet the surfaces. The point at which this line cuts the axis is the 
optical centre. Pays passing through it suffer no angular deviation. The 
principal focus of a convex lens is a point on the principal axis to which 








ERRORS OF REFRACTION. 


689 


parallel incident ravs are brought to a focus; and its distance from the lens 
is its principal focal distance. 

When a luminous point beyond the principal focus sends rays to a 
convex lens the emergent rays converge to another point; the two points thus 
related are called conjugate foci. When rays diverge from a point whose 
distance is equal to, or greater than, the principal focus, the conjugate focus 
is positive; when the distance is less than the principal focus, the conjugate 
focus is negative. 

A B C 



D 


E 



F 


(A) Double convex 

(B) Plano-convex 

(C) Concavo-convex 

(D) Double concave 

(E) Plano-concave 
(V) Convexo-concave 


^ Converging lenses, thickest at optical centre. 
1. Diverging lenses, thinnest at centre. 


The image of an object placed nearer the lens than the principal focus 
is virtual, magnified, and erect. When the object is situated at a greater 
distance from the lens than its principal focus, the image is a real, inverted 
one. The size of the object and its image are proportional to their respec- 






44 























G90 


MODERN OPHTHALMOLOGY. 


tive distances from the optical centre. The 'position of an image is found 
hy drawing two lines from each extremity of an object, one passing through 
the optical centre of the lens and one parallel to the principal axis; the 
latter will be refracted to the principal focus, and where these two lines inter¬ 
sect the image will be formed. 

The cardinal points of a concave lens are determined in the same way 
as those of the convex lens. * All parallel rays falling upon a concave lens 
diverge after refraction and can never come to a focus on the far side of the 
lens, but if they are followed backward it will be seen that they come to a 
point between the lens and the object. This point is the principal focus , 
and, as the light does not really pass through it, it is called a virtual focus. 

A cylindric lens is a lens one or both surfaces of which are segments 
of a cylinder, being composed of a series of prisms placed side by side. The 
resulting convergent points of every individual series composing the row 
must make a line of convergence. 

Cylindric lenses may have any of the general forms of spheric lenses. 
If the series of prisms are arranged with their bases together, a convex 
cylindric lens is formed; or concave if arranged with apexes together. 

The utmost refraction of a cylinder always occurs in the meridian at 
right angles to its axis. It acts only in one plane. To determine the axis 
of a cylindric lens, hold so as to see through it a part of some straight line, 
then turn the lens in its own plane until the part seen through it appears 
continuous with the parts above and below, the axis being then parallel to 
this line. 

For sphero-cylindric combinations the toric lenses are desirable, as 
they increase the field of vision and reduce spheric aberration. The toric 
lens has the difference of refraction of the two principal meridians ground 
on one surface and the other surface ground concave, giving a periscopic 
sphero-cylindric lens much superior to the universal grindings. 

Numbering of Lenses. —Lenses are numbered to indicate their focal 
distance, the unit being a lens having a focal distance of one metre and 
called a dioptre, the numbers expressing the refractive powers being mul¬ 
tiples of this lens. A lens having a focal distance of one metre would have 
the sign 1.00 D. to represent it; a plus or positive sign is prefixed (-{- 1 D.) 
if convex, and negative or minus (—1 D.) if concave. Should the lens be 
a spheric one, the sign S. is placed between the character and strength sign. 
If it be a cylinder, the sign C. is substituted for the letter S. and the axis- 
angle is expressed by the abbreviation ax. with the degree of angle added 
(+ C. 1 D.; ax., 90°). The combination of a sphere and cylinder would 
be written, if convex, in the following manner: -f S. 1 D. ^ + C. 1 D.; 
ax., 90°. 

A lens of two dioptres’ power (2 D.) focuses at one-half metre; a 4 D. 
lens at one-fourth metre. A lens that focuses at two metres is known as a 
0.50 D. One at four metres’ distance = 0.25 D. 

To find the focal length of a lens in the dioptric system divide one 


ERRORS OF REFRACTION. 


691 


metre, or one hundred centimetres, by the number of dioptres; thus, the 
focal length of a lens of 4 D. is 100 / 4 = 25 centimetres. 

The inch system was the old way of numbering lenses according to 
their radii of curvature expressed in inches. The unit 1 was a lens with 
a focus of about one inch. The successive strengths were expressed by 
fractional parts of 1; as a lens of 4-inch focus was expressed as 1 / 4 , and of 
40-inch, as 1 / 40 . 

To convert any strength of dioptre lens into an equivalent one of the 
old system, divide the dioptric number into 40 (there are 39.37 inches in a 
metre), and the inches of focal distance will be obtained. Or having the 
number of inches of focal distance of a lens and dividing it into 40 we get the 
number of the lens in the dioptric system. 

With the dioptric system the calculation necessary for any combination 
of lens-power is very easy. As example, a + S. 2 D. added to -f- S. 4 D. 
gives a lens of -f S. 6 D. Or, with unlike combinations, a -f S. 4 D. and 
a — S. 1 D. added together give a resultant of + S. 3 D. 



Fig. 390— Emmetropic eye. 


Similarly formed lenses produce results equal to their added powers, 
while dissimilarly formed lenses give results equal to their differences. The 
same rule holds good for cylinders in similar axes, while prisms increase in 
strength when placed base to base, and decrease in strength when placed 
edge to base. 

EMMETROPIA. 

Emmetropia is that condition in which the eye, in a state of rest, 
focuses parallel rays of light exactly on the layer of rods and cones of the 
retina (Fig. 390). While this is the mathematical definition of emme¬ 
tropia, it is impossible to consider the functions of the visual organ as domi¬ 
nated by any fixed mathematical laws. Such an eye cannot be termed a 
normal eye, for it may easily be abnormal or morbid and nevertheless be 
emmetropic. If the emmetropic eye be considered, as it scientifically should 
be. as a perfect visual mechanism, in which parallel rays of light are brought 
to’ a focus exactly on that part of the retina devoted to distinct vision when 
the eye is in a state of rest, it is doubtful that it has any existence at all. 
The emmetropic eye, as it is clinically seen at times, is but a temporary con¬ 
dition in what is known as diminishing hypermetropia —the transitional 





692 


MODERN OPHTHALMOLOGY. 


stage between hypermetropia and myopia, a refractive halt in an irritated or 
inflamed eye that needs treatment. 

An eye is normal in which the structures are free from disease asso¬ 
ciated with undisturbing physiologic action giving as nearly a normal visual 
result for both near and far as possible. The size or shape is of no conse- 
qiience. If it be healthy and acting properly, it is normal. 

An eye in which the principal focus falls on the retina may vary in 
its dimensions: the shorter the radius of curvature of the cornea or of the 
lens, the closer the retina would have to be to the dioptric surfaces. Coii- 
versely, the longer the radius of curvature of the cornea or lens, the further 
the retina must be from the dioptric surfaces. As extremes we may have 
an emmetropic eye with a corneal radius of 8.04 millimetres and an axis 
of 24.94 millimetres, or one with a corneal radius of 6.95 millimetres and a 
visual axis of 20.95 millimetres. Arlt adopts a corneal curve of 7.6 milli¬ 
metres and an axis of 24 millimetres as the average standard in emmetropia. 
In the newborn babe the average diameter in the visual axis is 17.495 milli¬ 
metres, the average horizontal diameter is 17.2 millimetres, and the average 
vertical diameter is 16.38 millimetres. 

Theoretically, the emmetropic eye is probably the best adapted for com¬ 
fort, and should always be sought for, even though it is a theoretic stand¬ 
point that cannot be gained. While it may be a broad general rule to 
restore the eye to a condition of emmetropia by suitable glasses, the condi¬ 
tion artificially obtained is not always the best for the well-being of the 
organ. A perfect vision obtained by neutralizing lenses may be fraught 
with increased physiologic action that is detrimental to the disturbed phys¬ 
ical material. 


AMETROPIA. 

When the dioptric surfaces do not perfectly focus the light passing 
through them, or when they do so focus it, but the retina is situated else¬ 
where, the eye is said to be ametropic. Alteration in the antero-posterior 
diameter of the eye by which rays do not cross one another properly, and the 
focus falls either in front or back of the retina, is known as axial ametropia. 
Error in the curvature of its lenses is termed meridional ametro.pia. Change 
of refractive strength dependent on peculiarities in the substance of the 
dioptric media themselves is designated as medial ametropia. When the 
principal focus falls behind the retina ( H , Fig. 391), the condition is known 
as hypermetropia. When the principal focus falls in front of the retina 
(M, Fig. 391), it is termed myopia. When there is more than one principal 
focus, it is termed astigmatism. 


HYPERMETROPIA. 

Definition. —Hypermetropia is that form of ametropia in which the eve 
in a state of rest focuses parallel rays of light behind the retina (Fig. 392). 


ERRORS OF REFRACTION. 


693 


The refraction power of the eye is so low or its axis is so short that, when 
the eye is in a state of rest, parallel rays are not united upon the retina, 
but behind it, and only convergent rays are brought to a focus upon that 
membrane. Inasmuch as all objects reflect either divergent or parallel rays, 
such an eye is. unable in a state of rest to see distinctly unless it can add 
to its refractive power. This is accomplished by using its accommodation. 
It can then cause its lens to become more convex and thus refract the rays 
more strongly, thereby causing the principal focus to be* thrown on the 
retina (Fig. 393). This additional convexity takes away a portion of the 





Fig. 391.—Refraction of parallel rays of light in emmetropia (E), 
hypennetropia (HJ, and myopia (M). 

accommodation power merely to preserve proper distant vision, leaving more 
or less of a minimum for purposes of accommodation. The result is that 
the near point will be farther removed from the eye; there will be a weak¬ 
ening of the dynamic or changeable power. Thus in Fig. 394 the parallel 
dotted rays have been sufficiently converged to be received upon the retina 
by the additional action of the lens, as shown by the dotted curve. A certain 
amount of lens-action has been lost in this procedure. The remaining por¬ 
tion is useful only for accommodation. There being less dynamic play of 
lens-strength, the near point will be situated at a much greater distance than 
in either emmetropia or myopia. 
















G94 


MODERN OPHTHALMOLOGY. 


Etiology.—The hypermetropic construction of the eyeball is congenital 
and often is hereditary. It is generally an imperfectly developed eye, the 
expansion of the retina is less, and there is a smaller optic nerve with a 
smaller number of fibres. The normal eyeball at birth is smaller in all the 
axes, as has been previously shown, and there is an hypermetropia of about 
3 dioptres, which is diminished by about one-thircl or one-half, not only by 
further development of the eye, but in many cases by pathologic change. 
In addition to the ordinary congenital abnormality of having too short a 



Fig. 392.-—Inability to focus parallel rays of light on the retina 
of the hypermetropic eye. 

visual axis or too weak a dioptric apparatus, the shortening of the antero¬ 
posterior diameter of even an emmetropic or a myopic globe so as to produce 
a marked hypermetropia by pressure has been attributed to augmentation of 
the retrobulbar contents of the orbit from vascular change, excessive adipose 
tissue, tumors, etc. Forward displacement of the retina in the macular 
region by localized chorioidal disturbance or submacular exudate may so 
lessen the power of the refractive constants in the visual axis as to increase 



Fig. 393.—Accommodation is necessary to bring parallel rays on the 
retina of the hypermetropic eye. 

an already existing hypermetropia, or reduce a myopia or emmetropia to an 
hypermetropia. Flattening of the cornea from traumatism and inflamma¬ 
tion, and lid-pressure on the anterior face of the eyeball, are said to be the 
causes. Aphakia, or absence of the lens, is one of the most frequent causes 
of acquired hypermetropia. 

Pathology.—In many cases of hypermetropia the orbits are more 
shallow than in emmetropia or in myopia, the margins are flattened and 
widely separated, the eyes are wide apart, and the nasal bone is depressed. 







ERRORS OF REFRACTION. 


695 


There is congestion of the lids and conjunctivse, which may become aggra¬ 
vated into formation of pustules along the margin of the lids—in the 
majority of instances associated with microbic invasion. Hordeola and 
Meibomian-gland cysts are frequently seen. There is hypertrophy of the 
internal muscles. The sclerotic is thickened and dense. The circular fibres 
of the ciliary muscle are generally hypertrophied. In the higher degree of 
hypermetropia the hypertrophy is so great that there is either a right angle 
or an obtuse angle formed at the junction of the anterior and the external 
surfaces. This is less so in emmetropia. In high myopia the angle is often 
quite acute. The extra exertion pqt upon the ciliary muscle to overcome 
the optical defect causes an increased flow of blood to the eye. The optic 
disc at times exhibits a low-grade inflammation. The lymph-channels of 
the main retinal vessels are often thickened and opaque, while the veins 
may be somewhat engorged. The retina and the chorioid are not infre¬ 
quently congested, especially in the region of the macula lutea and of the 
optic disc. The fovea centralis is situated quite distant temporally from 
the outer edge of the optic-nerve head. 



Fig. 394.—Additional accommodation power is necessary to bring an object at 
the near point upon the retina of an hypermetropic eye. 

Symptoms.—The symptoms are (1) subjective and (2) objective. 

1. Subjective Symptoms. —Low and medium grades of hypermetropia 
are normal in the eyes of all the human race which are not excessively and 
constantly used for near work. It is only when the vision becomes indis¬ 
tinct or painful because of diminished power of accommodation, oi higher 
hypermetropia, that the patient seeks relief of the physician, who should be 
thoroughly familiar with those symptoms and their causes. 

In the lower grades of hypermetropia, especially in the middle-aged or 
in those using their eyes for observation of minute objects at close distances 
many hours daily, the patient complains of the eyes tiring easily. They 
finally get sleepy, their lids become heavy, their eyes itch or burn, and the 
print begins to blur during continued near work. They are compelled to 
stop, and a sense of relief is felt by pressing the eyes and forehead with the 
hands. Work is resumed, but the symptoms recur. This is repeated 
until the accommodation becomes exhausted (accommodative asthenopia) 
and the patient is forced to discontinue work. The symptoms are always 
aggravated by artificial light. If work is persisted in, headache over the 
eyebrows and in the temples generally appears. 



696 


MODERN OPHTHALMOLOGY. 


In the higher degrees of hypermetropia the ciliary muscle is so little 
able persistently to combat the defect that any effort at continued near 
work is relinquished. In healthy young people the eye is able temporarily 
to overcome the error by severe and persistent effort, but the hours of work 
cannot be maintained continuously. The effort and strain on the part of 
the ciliary muscle are shown by pain in the eye or temple and forehead. 
In aggravated cases the pain shoots through the top of the head to the 
occipital region. Often the neuralgia is so intense that any change of 
tension in the ciliary muscle becomes painful, and reflex disturbances, 
usually consisting in sensations of dizziness and nausea, are developed. 
These symptoms are excited by work requiring rapid change of focus, as 
in bookkeepers, pianists who alternately glance at a sheet of music and the 
keyboard, or in those learning typewriting before the necessary manual 
movements have become sufficiently automatic not to require any fixity of 
gaze upon the variously placed characters. Less severe, but similar, symp¬ 
toms occur in low grades of hypermetropia in persons who are convalescent 
from acute disease, or in those who have enfeebled or broken-down nervous 
systems, and in women with pelvic disease, uterine displacement, etc., espe¬ 
cially marked at the menopause, and during irregular menstruation, appear¬ 
ing after prolonged periods of abuse of the eyes, or during mental anxiety 
or undue fatigue. The symptoms are most severe soon after rising. The 
patient complains of pain in the back and top of the head, accompanied by 
great discomfort and dull pain deep in the orbits immediately back of the 
eyes. The ready fatigue of the eyes on very slight use and the neuralgia, 
discomfort, and blur caused by slight and moderate degrees of hyper¬ 
metropia may also be very early symptoms of posterior spinal sclerosis. 

In the hypermetropic eye the acuteness of vision is often diminished. 
In the slight degrees there is seldom any difference to be observed, but in 
the higher degrees of hypermetropia among the young, and in nearly every 
case in subjects who are beyond forty-five or fifty years, visual acuity for 
both distant and near work is reduced below the standard. 

On account of the shorter distance between the nodal point and the 
retina, the retinal images are smaller than in the emmetropic eye, and, even 
after the correcting convex spheric lenses are placed properly before the eves 
so that the retinal images may be considered to attain the normal magnitude, 
the acuteness of vision in many cases does not reach the normal, probably 
because the smaller optic nerve does not possess the same number of nerve- 
fibres and the smaller surface of the retina does not contain the same num¬ 
ber of percipient elements as the emmetropic eye. 

In the very highest degrees of hypermetropia the retinal images become 
so small that the patients bring objects close to their eyes in order to make 
the images larger. At the same time they nip their eyelids so as to reduce 
the diffusion circles. This symptom may be mistaken for myopia, but can 
be distinguished by the want of uniformity in the distance at which the 
patient places his book. He holds the book far off, then again closer, and 


ERRORS OF REFRACTION. 


697 


even if the print is large and distinct he is often unable to read fluently 
at any distance. 

What properly characterizes the vision of the hypermetrope is not the 
diminished acuity of vision, but the recession of the near point, which is 
especially pronounced during monocular vision. As was previously ex¬ 
plained, the emmetropic person relaxes his power of accommodation as 
much as possible and then sees acutely a-t any infinite distance; but the 
hypermetropic individual in order to see at a distance must bring his 
power of accommodation into action; consequently there is less power 
left to focus near objects, the lens reaches its maximum tension earliest, and 
for that reason the patient is forced to hold objects farther away from the 
eye than the emmetropic. This constant contraction of the ciliary mus¬ 
cle frequently produces a spasm of the accommodation, especially in netiras- 
thenic individuals, giving rise to annoying blurring of distance vision; both 
the near and the far point are brought nearer the eye, and vision is im¬ 
proved by concave lenses, which, of course, should never be ordered, as they 
would only increase the trouble. The condition simulates myopia, and 
might be mistaken for such by a careless observer unless the eye is brought 
thoroughly under the influence of a cycloplegic. 

The concealing power of the ciliary muscle and lens has given rise to 
the description of three varieties or types of hypermetropia in ophthalmic 
nomenclature. When the defect is completely concealed by the accommo¬ 
dation in both distance and near vision it is known as latent hypermetropia, 
and has the symbol HI. That portion which remains uncorrected and is 
exposed, giving rise to painful or indistinct vision of near objects or misty 
outlines of distant ones, is designated manifest hypermetropia , expressed by 
the abbreviation Hm. In other words, it is that part of the defect that 
can be corrected by convex lenses without the use of a cycloplegic, whereas 
the latent can be developed only by completely paralyzing the ciliary 
muscle. The entire amount of the error obtained by adding together the 
manifest and latent is termed total hypermetropia —expressed by the ab¬ 
breviation Ht. 

Manifest hypermetropia is further divided into facultative hyperme¬ 
tropia (Hf), which exists when objects can be seen accurately at infinity 
with and without convex lenses, and without any convergence being neces¬ 
sary; relative hypermetropia (Ilr), in which there is only sufficient accom¬ 
modation to neutralize the defect by an undue effort at convergence; and 
absolute hypermetropia (Ha), when, even with the strongest convergence 
of the visual lenses, accommodation for near and far vision is impossible— 
objects being seen indistinctly at any distance. 

2. Objective Symptoms. —The physiognomy is often characteristic of 
hypermetropia, especially in the higher degrees. The eyelids are flat and 
broad; the eyes are small, widely separated, sometimes deep-set, and at other 
times they arc superficial. By some the orbits are said to be shallow, with 
flattened and widely separated margins; others describe them as being both 


698 


MODERN OPHTHALMOLOGY. 


high and narrow. The whole face is flattened; there is little rounding in 
the cheeks. The nose is but slightly prominent, with depressed nasal 
bridge. Not infrequently there is thickening of the conjunctiva, with stilli- 
cidium and epiphora, and a predisposition to herpetic disease of the cornea. 
Immediately around the cornea the sclerotic has a flat, slightly curved ap¬ 
pearance. At the equator the eyeball is sharply curved and bulging. The 
cornea does not share in the imperfect development of the remaining 
structures, which prevents the hypermetropic eye being classed as true 
microphthalmos'. It has the appearance of being more convex, due solely 
to the shallow anterior chamber and small pupil. 

In hypermetropia there is an apparent divergent strabismus when look¬ 
ing at a distance, due to the increased width of angle alpha —the angle 
formed by the visual line, which proceeds from an extraneous object directly 
through the nodal point to the macula lutea of the eye, and a line through 
the axis of the cornea, on the horizontal plane. The visual line in emme- 
tropia passes to the nasal side of the axis of the cornea. The macula lutea 
in the hypermetropic eye is situated farther to the temporal side of the 
optic-nerve head than in emmetropia. Consequently the visual line cuts 
the cornea farther to the nasal side, increasing the angle alpha in high- 
grade cases to nearly double the width of that which is found in emme¬ 
tropia ; so that in hypermetropia in order to give a parallel direction to the 
visual line an extraordinary divergence of the visual axes is necessary, and, 
if in distance vision the necessary divergence of the corneal axes is insuf¬ 
ficient, the convergence in looking at near objects will he relatively too 
great—a condition that facilitates the development of convergent strabismus. 

In hypermetropia the patient must make an effort of accommodation to 
remedy the insufficiency of his static refraction. For every increment of 
nerve-force sent to the accommodation an equal amount is sent to the con¬ 
vergence, and, as an equal amount of nerve-force is sent to the accommoda¬ 
tion and convergence of the two eyes, there must be an excess of convergence 
produced, which is still further exaggerated when the patient looks at a 
near object. This effort on the part of accommodation and convergence 
being in constant use in order for the hypermetrope to have clear vision, the 
habit of convergence is formed, which causes an increase in the develop¬ 
ment of the converging muscle with a corresponding weakening of the ab¬ 
ductors, and the convergence becomes pathologic, but does not manifest 
itself at the same time in both eyes. 

The nerve-force necessary to keep the eye directed upon the object is 
equally divided between the muscles of the two eyes, but in one it main¬ 
tains the equilibrium between abductor and adductor muscles, while in the 
other, in which the sight is more feeble and the image more easily sup¬ 
pressed, it goes entirely to the adductor, forming an angle double that which 
would be necessary if the convergence were ► symmetrical. Therefore we 
ordinarily see but one eye “squinting.” It usually develops early in life, 
in poorly nourished children, when they begin to fix their attention upon 


ERRORS OF REFRACTION. 


699 


objects shown them or upon first entering school. It generally begins by 
being periodic , or alternating; later it becomes permanent and localized 
to one eye, generally the weaker, although it may alternate for years. It 
occurs principally in the medium degrees of hypermetropia. dhe higher 
degrees do not “squint,” because good vision is out of the question under 
any circumstance. 

Not all hypermetropes have strabismus, because of the innate tend¬ 
ency to binocular vision and the changeable relations between accommoda¬ 
tion and convergence. Convergent strabismus from hypermetropia tends 
gradually to diminish as the patient grows older and often passes off spon¬ 
taneously; so that it is rare after the age of forty. Of course, there are 
other causes of convergent strabismus which are discussed elsewhere in 
this book. 

Ophthalmoscopic Appearance.— In examining an hypermetropic 
eye with the ophthalmoscope by the direct method, the fundus appears bril¬ 
liantly illuminated; the ophthalmoscopic field is greatly enlarged. The 
low degree of magnifying power causes the optic disc to appear smaller 
than in emmetropia, and if the observer be emmetropic and his accommo¬ 
dation be relaxed, it will require a convex lens revolved before the sight- 
hole to render the image distinct. This is all that will be observed in the 
very low grades of hypermetropia. 

In the moderate degrees, in addition to the appearance mentioned, 
there is increased redness of the optic disc, congestion, and tortuosity of 
the retinal veins, which is most marked near the disc. The thickening of 
the lymph-channels of the main retinal vessels produces a bright yellowish- 
white reflex, shifting with the motion of the mirror. The epithelium of the 
chorioid presents a smooth, hazy appearance. Frequently there is con¬ 
gestion of the chorioid and retina, especially in the region of the optic 
disc and the macula lutea. 

In the higher degrees of hypermetropia the media are clear and the 
disc, retina, and chorioid appear nearly normal, because the patient cannot 
overcome his defect by increasing the accommodation to secure distinct 
vision. Therefore, with less physiologic action, less blood is sent to the 
eye, and the eye does not present the congested ophthalmoscopic picture of 
the*lower grades, in which the patient can secure distinct vision by increas¬ 
ing the accommodation, thereby inviting an increase of blood to the eye. 

Diagnosis.—The history of headaches coming on during or after the 
use of the eyes; the usually slight impairment of distance vision, which may 
be improved by the addition of convex lenses; the removal of the near 
point farther from the eye than is proper for the age; the fact that the 
patient can read fine print through a convex lens at a greater distance than 
its principal focus; the characteristic mold of the face—the thickened and 
irritated conjunctiva, the small eyeball, sharply curved at the equator; 
possibly a convergent strabismus; the narrow anterior chamber; the small 
pupil; the great width of the ophthalmoscopic field and small image in 


700 


MODERN OPHTHALMOLOGY. 


the direct method; the fundus-image test, and the fundus-reflex test (de¬ 
scribed elsewhere), all determine the presence of hypermetropia. 

Treatment. —It must be remembered that hypermetropia of low grade 
is the normal state in the eyes of all the human race which are not ex¬ 
cessively and constantly used for near work, and that the proportion of 
hypermetropes is much greater among children than among adults. The 
eye participates in the general development and there is a gradual diminu¬ 
tion of the hypermetropia during the period when the entire organism is 
growing and acquiring its definitive form. Therefore hypermetropia should 
receive treatment only when it produces asthenopia or insufficiency of sight. 

As we possess no radical cure for hypermetropia, we must resort to 
the most effective palliative remedy—convex lenses. Such glasses, by 
adding their refractive power to that of the eye, can supply any deficit in 
the latter and correct no matter what degree of hypermetropia. 

Theoretically it would appear right to neutralize the hypermetropia 
by a convex lens, and thus change the eye into an emmetropic one, this lens 
forming, so to speak, an integral part of the eye. But in practice we find 
that this is undesirable, and that such patients will reject such glasses so 
long as they can see distinctly at a distance without asthenopia. This 
arises from the fact that eyes which since childhood have been accustomed 
to strain their accommodation and convergence in the effort to see dis¬ 
tinctly, and have thus acquired hypertrophy of the ciliary muscles and of 
the internal recti, are unable at once to reverse their habits of work with 
comfort. 

In addition, it must be remembered that any glass, no matter how well 
fitted to the eye and face, is a nuisance by giving rise to circles of diffusion 
which arise from reflected images of brightly illuminated objects striking its 
posterior surface, thus making the edges and rim of the glasses unpleasantly 
apparent. Disagreeable feelings in the nose, temples, and ears are also often 
occasioned by the weight of the glasses and the pressure of their frames. 
If distance vision is made much more distinct with the glasses, or if head¬ 
ache and eyestrain are relieved by their use, the advantages resulting from 
their employment lead the patient to habituate himself to them and to 
neglect the inconveniences. But we should abstain from giving spectacles 
except in cases of absolute necessity. 

When spectacles are found necessary they should be ordered and ad¬ 
justed by a physician. If opticians would devote their energies to grinding 
lenses properly and perfecting optical instruments, they would do more 
toward furthering the service of medicine, and relieving the suffering of 
humanity than by attempting to do something for which they are ill or 
not at all prepared. Too much cannot be said against the pernicious habit 
of opticians ordering glasses, which are as much a medicine for the dis¬ 
eased and complaining eye as is digitalis for a diseased heart. The pharma¬ 
cist is far better prepared to administer the digitalis than is the ojotician to 
order glasses. 


ERRORS OF REFRACTION. 


701 


The eye must be regarded, not as a separate organ, but as a highly 
specialized part of the whole body. The ordering of glasses does not con¬ 
sist merely in placing lenses before the eye and ordering that which gives 
the best vision. The choice of glasses is a delicate operation; he alone is 
successful in it who, to a perfect theoretic acquaintance with the subject, 
adds the intelligent observation of each patient. It does not suffice to 
know the action of lenses and the workings of the visual organ. He must 
consider the state of accommodation and refraction, that of the muscles of 
the patient’s eyes, the particular purpose of his wearing glasses, his peculiar 
habits, and the constitutional state of the patient. 

Persons who are convalescent from acute disease, or those who have 
feeble health and impaired nutrition, as well as those who have hyper¬ 
esthesia of the nervous system, suffer acutely from low grades of hyperme- 
tropia which would produce no symptoms of discomfort at the same time of 
life were they in robust health. 

In the hyperesthetic state preceding central nerve degeneration, and in 
the various disturbances of health accompanying uterine or ovarian dis¬ 
ease, adolescence, or the change of life, we frequently see that the correction 
of liypermetropia of even 0.25 D., or equivalent change in glasses already 
worn, relieves headache and nervousness, and enables the patient to perform 
his daily task with less discomfort. Again, persons who, in an enfeebled 
state of health, have found spectacles absolutely necessary for comfort, can 
perhaps lay them aside when they have regained their accustomed health. 

As can be well seen, it is impossible to make rules for the treatment of 
refractive errors which may be blindly followed, relieving the oculist from 
the necessity of reflecting and combining for himself. 

A correction should be prescribed in all cases of marked local vascular 
disturbance or where there is asthenopia. To ascertain this condition in 
young people, it is necessary to obtain the absolute amount of refractive 
error. This is done by placing the ciliary muscles under the full influence 
of a cycloplegic. Without such drugs it is impossible, except in the middle- 
aged and in the old, to ascertain the total liypermetropia, either by test 
glasses, by the ophthalmoscope, or by the shadow test. 

Having ascertained the total amount of liypermetropia by the various 
methods described elsewhere in this book, the question is: what shall we 
order? The full correction placed before the eye while yet under complete 
influence of the cycloplegic gives distinct distance vision, but the same cor¬ 
rection placed before the eye after the effects of the drug have disappeared 
will possibly not give anywhere near normal distance vision, and all distant 
objects will appear hazy, which clears entirely upon removing the correc¬ 
tion, and yet if no correction is worn the asthenopia and vascular disturb¬ 
ance return. What is to be done ? 

This may be overcome by ordering the full correction to be worn con¬ 
stantly while the eyes are still under the effect of the cycloplegic, and, if 
this correction produces indistinct distance vision after the eye has regained 


702 


MODERN OPHTHALMOLOGY. 


its normal condition, the glass may be weakened until full acuity of vision 
is obtained. Or we may first allow the eyes to regain their full power of 
accommodation; the full correction is then placed before the eyes, and, if 
full acuity of vision is obtained, it may be ordered. But usually the vision 
is reduced considerably. The patient is then requested to read as much as 
possible on the test-card, the strength of the glasses being gradually weak¬ 
ened until full acuity is obtained, and the strongest glass that gives full 
acuity of vision is ordered. The latter method should be followed when¬ 
ever possible, as the results are more certain. 

The principal objection to ordering from the post-cycloplegic examina¬ 
tion is the delay to the patient in securing his glasses. This is an important 
consideration to most patients, but if one of the more rapidly acting cyclo- 
plegics be used, such as scopolamin,—which paralyzes the accommodation for 
ninety-six hours,—this objection is overcome, and, furthermore, if it should 
be necessary for the patient to use his eyes occasionally during this time, 
he can be supplied with a pair of -j- 3.00 or -j- 4.00 spheres. 

Another objection to this method is that the total H is uncorrected. 
But it must be remembered that it is not always desirable or even safe to 
convert the eye into an emmetropic condition, and that the acquired hyper¬ 
trophy of the ciliary •muscles and of the internal recti cannot be lost at 
once. Consequent^, when the full correction is placed before the eyes, 
there is an annoying blurring of distance vision, with headaches and gen¬ 
eral discomfort. It is true this may be overcome by using a very weak 
solution of atropin daily until unpleasant symptoms have disappeared, but 
few patients will submit to being deprived of their near vision for any con¬ 
siderable length of time. Of course, if there is any inflammatory condition 
within the eye caused by the H, atropin should be used until such condition 
has subsided before any correction is made, the tension being watched 
constantly. 

Ordering glasses for the manifest error only, without any knowledge of 
the total H, is not to be thought of except for adults in whom the use of a 
cycloplegic to allow the immediate estimation of the total H is inconvenient 
or impossible. It is unscientific and harmful to the patient. The same may 
be said of arbitrarily deducting a certain amount from the total H. 

As has been said before, there can be no rule to follow blindly in all 
cases. But the writer believes the method that will give greatest satisfac¬ 
tion to the patient is to make a careful estimation of the total H, and, after 
the accommodation has returned, place the full correction before the eyes 
and direct the patient to begin with the large letters and read slowly down 
the card while the correction is lessened 0.25 D. each time, forcing the 
patient to read the lowest line possible at each reduction, until full acuity 
of vision is obtained, ordering the strongest glass which gives such vision. 
If this glass is very much weaker than the total H, it should be worn only 
for distance, and the full correction prescribed for all near work. In order¬ 
ing full correction, it should be remembered that, while rays of light coming 


ERRORS OF REFRACTION. 


703 


from a point five or six metres distant may be considered practically parallel, 
strictly speaking they are not, and a glass that gives fullest acuity of vision 
at that distance will not focus parallel rays. Therefore it does not repre¬ 
sent the total IT, but an overcorrection of 1 / 5 to V 4 D. Consequently that 
glass which gives the best vision at five or six metres should be weakened by 
Vs or Ve D- 

If there is insufficiency of convergence (exoplioria) present, full cor¬ 
rection is contra-indicated, whereas if there be esophoria, full correction will 
be worn with greater comfort. 

If the glass correcting the total hypermetropia be placed before the 
eye while the accommodation is paralyzed, and a + 4 D. sphere is placed in 
front of that, the patient should be able to read small type distinctly at 
twenty-five centimetres—the focal distance of the lens. If the patient reads 
best at a point beyond this, the hypermetropia is not fully corrected, whereas 
if it is read nearer than twenty-five centimetres, the hypermetropia is over¬ 
corrected. 

Convergent strabismus caused by hypermetropia, if in a child too young 
to wear glasses, may be treated by instillation of a weak solution of atropin 



Fig. 395.—Illustrating the focus of parallel rays of light in the myopic eye. 

in both eyes ( 1 / 2 to 1 grain to the ounce), and the eyes protected from light 
by a veil or shade. As soon as the age of the child permits, he should be 
given glasses that correct the full amount of H, and advised to use the eyes 
for near work not more than a few hours each day, with frequent intermis¬ 
sion. The cycloplegic may be gradually withdrawn until discontinued. 

If the visual acuteness in the convergent eye is very slight, the refrac¬ 
tion-error should be carefully corrected, and then the deviating eye should 
be given special training, while the healthy eye is excluded. The exercise 
should never be continued until fatigue is produced. In this manner the 
visual acuteness can be considerably augmented. 

If the strabismus persists after the above treatment has been carefully 
followed, it then becomes a case suitable for one of the several operations 
described elsewhere in this book. 

MYOPIA (HYPOMETROPIA). 

Definition.— Myopia is that form of ametropia in which the eye in a 
state of rest focuses parallel rays of light in front of the retina (Fig. 395). 





704 


MODERN OPHTHALMOLOGY. 


In the emmetropic eye in a state of rest parallel rays are brought to a focus 
directly on the retina. The refracting power of the eye and the length of the 
visual axis are equal and a perfect image is formed on the retina. In hyper- 
metropia the eye when at rest focuses parallel rays of light behind the retina. 
There is an insufficiency of refracting material, or the eyeball is too short 
and only convergent rays can be brought to a focus on the retina when the 
eye is at rest. The far point is beyond infinity and the near point is farther 
from the eye than was proper for the age. In myopia, the eyeball being too 



Fig. 396.—Only divergent rays are brought to a focus on the retina. 

long or there being too much refracting material, the focus falls in front 
of the retina in the vitreous, and only diffusion circles are formed on the 
retina. Only divergent rays of light can be brought to a focus on the retina 
(Fig. 396). Consequently the far point is at a finite distance: i.e., it is 
near the eye. The near point is also brought nearer the eye. 

The myopic eye has just as much lens-power as the hypermetropic or 
emmetropic eye, but in the hvpermetrope a certain amount is lost in main¬ 
taining distinct distance vision, thus having less power available for focus- 



Fig. 397.-—Parallel rays focused in the vitreous. 
li, Far point. P, Near point. 


ing near objects. The myope, not being compelled to use.any of the 
power for distance vision, has that much more for focusing near objects, and 
in addition is assisted still further by the long visual axis, which enables 
him to see even closer than the emmetrope. Fig/397 shows the far point 
and near point in myopia, with increase in the curvature of the lens for the 
near point. 

Etiology.—Myopia is due to increase of the length of the visual axis 
by stretching of the eyeball at the posterior pole (axial M.). Myopia may 
be produced practically by excessive curvature of the cornea, as in staphy- 







ERRORS OF REFRACTION. 


705 


loma of the cornea and conic cornea, or in the early stage of cataract, when 
the lens swells and increases the curvature (curvature M.), or the lens may 
he dislocated forward. It is also produced in spasm of the ciliary muscle; 
or, in fact, every time the lens accommodates for objects inside of the far 
point a practical myopia is produced. But these conditions do not cause a 
true myopia. The term myopia is applied only to the eyeball in which the 
increase of the length of the visual axis is due entirely to the stretching of 
the structures at the posterior pole. 

There are numerous theories to account for the causation of myopia. 
It is believed by some to he due to a hyperinclusion of mesoblastic vitreous 
material into the secondary optic vesicle. By others it is believed that it 
depends upon the size and shape of the orbit—that the vertical diameter of 
the orbit is increased. By others the contrary condition is claimed—that in 
low orbits there is such a variation in the course and insertion of the 
superior oblique muscle, due to the low position of the trochlea, that it 
increases the amount of force, or compression, which this muscle exerts 
upon the eyeball. The dragging effect on the lamina cribrosa at the weak¬ 
ened portion of the eyeball,—the optic-nerve entrance,—associated with the 
increased compression, is certainly a contributing factor of the mechanics 
in the inflammatory and degenerative processes of myopia, when occupation 
necessitates continued vertical movements of the eyeball. 

Others assert the cause to be due to compression of the globe by the 
external rectus muscle during excessive convergence made necessary 
by the short distance at which myopes must hold objects to observe clearly, 
the eyeball stretching posteriorly. Compresssion of the vorticose veins 
by the inferior oblique and external rectus muscles is also advanced as a 
solution of the etiology. Again, it is believed by some to be due to an 
inflammation of the chorioid and sclera at the posterior pole produced by 
constant congestion made necessary by occupation, in which the stooping 
position is assumed, or from compression of the jugular veins by bending 
over improperly adjusted desks or books, interfering with the return of 
blood from the eye, leading to congestion and subsequent inflammation. 

Abnormalities of the retrobulbar portion of the optic nerve not per¬ 
mitting proper movement of the eyeball is yet another reason given. It ace 
is also claimed as an etiologic factor. It is claimed that the broad, low 
face of the German contains the conditions for the production of myopia, 
but it seems more reasonable to presume it to be due to a previous want of 
proper correction of hypermetropic astigmatism. Since the disease has 
received the proper scientific investigation and more attention has been 
paid to hygiene in the school and home, it has rapidly decreased. 

Myopia is far less prevalent in this country than in Europe, especially 
Germany, where it is a national defect. In this country more attention 
is given to out-of-door sports and exercise, and not so much to the close 
application of detail and great reverence for past work, that characterizes the 
sedentary, plodding German nation. Myopia is said to be unknown among 

45 


706 


MODERN OPHTHALMOLOGY. 


the Nubians, the Laplanders, the Patagonians, and the peasant classes 
of Europe. It is less frequent in the eastern portion of the United States 
than formerly, due, no doubt, to the improved methods of scientific investi¬ 
gation and the correction of minor degrees of hypermetropia and astigma¬ 
tism. Jews are said to be more subject to myopia than Christians of the 
same social class. Since the abolition of slavery in this country and the 
introduction of higher educational methods, the student class of negroes 
has begun to develop myopia. 

Myopia is very rarely congenital. That there is some hereditary tend¬ 
ency in the form of the myclpic eye there can be no doubt. Just as the 
susceptibility to tuberculosis is passed from parent to child, so may the 
tendency to myopia be inherited. Myopia is as truly a disease as is tubercu¬ 
losis, and, if an individual can be born with “something” in the economy 
or a lacking of “something” that predisposes that individual to the ravages 
of tuberculosis when exposed to the contagion, so might it be possible to in¬ 
herit an eyeball the structure of which predisposes it to the development of 
myopia when placed under conducive conditions, of which the most impor¬ 
tant are improper illumination and hypermetropic astigmatism. 

Almost all eyes are hypermetropic at birth and very few are free from 
astigmatism, and, comparing these with the number of myopes, it is evi¬ 
dent that there is something necessary for the development of myopia other 
than hypermetropic astigmatism. But, given an eye predisposed to myopia 
and forced to work at a short distance under a poor light, the vision being 
already reduced because of the hypermetropic astigmatism, objects will be 
held closer than they should be in order to obtain a large retinal image, 
thereby making an undue effort at accommodation with exaggeration of 
convergence. Following the law of nutrition, an increased flow of blood is 
invited to the eye to carry nourishment to the constantly active ciliary 
muscle, producing first a congestion and later an inflammation of the ocular 
tunics. The increase of tension due to the increase of fluids within the eye 
presses upon the impoverished and diseased tissue. Not being able to with¬ 
stand the strain, there is a consequent giving way in the direction of least 
resistance, which is in the posterior segment of the globe. The further 
progress is hastened by the formation of the orbit and the insertion of the 
extra-ocular muscles compressing the globe still further and causing the 
refraction to change from hypermetropic astigmatism to mixed astigmatism 
and finally over to myopia with astigmatism. 

All children, especially improperly nourished children (both of rich 
and poor), are put to using their eyes for near work at an age when they 
should be having outdoor exercise and the eyes should be resting on distant 
objects. For this reason kindergarten work is harmful. It trains the 
mind by systematic play, but does so at the expense of the eyes, and it is 
quite likely that the beginning of myopia could be traced to kindergarten 
and primary-school work done under bad hygienic surroundings, combined 
with uncorrected hypermetropic astigmatism. 


ERRORS OF REFRACTION. 


707 


That school-life has harmful influences upon the eye is very clearly 
shown in the adjoining diagrams from statistics collected by Eisley in Phil¬ 
adelphia schools and Erismann in St. Petersburg. In Fig. 398 it is seen 
that, at the beginning of school-life,—eight and a half years,—88.11 per 
cent, of the eyes examined were hypermetropic, with only 4.27 per cent, 
myopic. Then there is a gradual sinking of hypermetropia until the age 
of seventeen and a half years is reached, when it is present in only G6.84 
per cent., and at the same age myopia has increased to 19.33 per cent. Fig. 
399 shows the very rapid sinking of hypermetropia and rise in myopia as 
the pupil advances in school-life in Europe as compared with the United 
States. Cohn’s statistics show the very rapid increase of myopia from 1.4 
per cent, in the lower grades to 59.5 per cent, in the university. 



Fig. 39S. 



Fig. 399. 


Study in itself is not the cause of the great increase in myopia as the 
pupil progresses. Potent factors are: Studying of hooks poorly printed, 
with small type, lines too close together and extending across the page; 
improperly adjusted desks and stools, poor illumination, faulty ventilation, 
too long hours of study with insufficient intervals, combined with uncor¬ 
rected hypermetropic astigmatism. That bad hygiene in the school-room 
is not alone the cause of myopia is shown in the studies made by Derby, 
Cohn, and Yust, showing the steady increase of myopia in schools having 
perfect hygienic surroundings and where great attention is paid to physical 
culture. Almost all authorities agree that the perfect hygienic arrange¬ 
ment of the school-room alone will not prevent the development of myopia. 

There are some who regard the change in refraction as a process of 
normal evolution, and claim the myopic eyeball is better suited to the needs 
of civilization than is either the emmetropic or hypermetropic globe. In 



























































708 


MODERN OPHTHALMOLOGY. 


order to sustain this opinion it would be necessary to show that this change 
of refraction from hypermetropia to myopia does not interfere with the 
health and comfort of the eye. That quite the reverse of this is the truth 
is clearly demonstrated in Figs. 400 and 401, which show (in Fig. 400) 
the gradual increase in disease of the eyeball with the state of refraction 
passing from hypermetropia over to myopia, and (in Fig. 401) the increase 
of asthenopic symptoms as the refraction increases, which is quite suf¬ 
ficient to prove that the increase of refraction is not a physiologic process, 
but the result of diseased structure, and that, instead of its being a com¬ 
fortable, the eye is a complaining organ. 

Those living in cities are more susceptible to the development of myopia 
than inhabitants of country districts, where social and commercial competi¬ 
tion is less marked. The unnecessary prolongation of the school-term, with 



too short vacation, with the consequent enervation of the growing child, 
obtain in the city, as compared with limited term of school and extended 
vacations made necessary in the country. There the eye rests on objects at 
infinite distance, little exertion of accommodation and convergence being 
required even in the hypermetropic organ. The air is fresh, water pure, 
food clean and wholesome, and as a result there is an absence of the be¬ 
spectacled, stoop-shouldered, narrow-chested, prematurely old children seen 
in all large commercial centres. 

The susceptibility to myopia is most marked when both parents are 
myopic, less when the mother is affected, and least when the father alone 
is myopic. When both father and mother are affected, it is seldom that 
the children escape. It is claimed bv some that the susceptibility is most 
frequently passed from mother to daughter. 































ERRORS OF REFRACTION. 


709 


Acquired myopia is said to begin from about the eighth year upward, 
but the process usually has its inception in a diminished hypermetropia 
with astigmatism, at a much earlier period, and ophthalmoscopic changes 
would undoubtedly be seen if looked for. During the period of adolescence 
myopia is almost always progressive. Puberty seems to affect the resisting 
power of the tissues, but, if the myopia does not attain a high degree during 
this period, it may become stationary when the body has completed its devel¬ 
opment and growth—about the age of twenty to twenty-five years. If the 
myopia reaches a high degree during youth, it is less likely to become sta¬ 



tionary. Vision will grow gradually less useful until the age of fifty or 
sixty years is reached, when the patient frequently becomes blind, dhe 
period from the fifteenth to the twenty-fifth year seems to be the time 
during which the myopia is most likely to progress both in degree and 
rapidity—the higher the degree, the more rapidly it progresses. Myopia 
seldom develops in an eye previously sound after the twentieth year. When 
there is only a trace of myopia present in youth, it almost always increases 
in degree, and the greatest care leads to nothing more than a limitation of 

the degree. 































































710 


MODERN OPHTHALMOLOGY. 


Myopia is seen most frequently in the more successful members of a 
community, and in those whose occupation requires close observation, such 
as compositors, brass-turners, etc. Although, frequently, high degrees of 
myopia rapidly progressive may occur in those whose eyes are never per¬ 
sistently applied for near work, some of the most malignant forms have 
been seen in sailors and laborers. Consequently myopia is not always a sign 
of superior mentality, and is not a characteristic of the student any more 
than of the artisan whose trade requires accurate near vision, if his work 
was begun early in life. 

Pathology.—Myopes have on an average a less convex cornea than 
emmetropes. The anterior chamber is deeper. The pupil is wider, due to 
atrophy of the pectinate ligament. The crystalline lens is not more con¬ 
vex than in emmetropia. It is claimed that the lens is flatter. The circu¬ 
lar fibres of the ciliary muscle are atrophied and are almost entirely want¬ 
ing. The longitudinal fibres are greatly hypertrophied. With the increase 
in length of the myopic eyeball the vitreous humor must either increase in 
size or leave a space between it and the retina, which space soon becomes 
filled with serum. Frequently there is a softening of the posterior part of 
the vitreous, and a breaking down of its structures, with the formation of 
floating opacities. The vitreous may become detached. 

In high degrees of myopia the drag upon the retina is so great that it 
is torn most frequently at the equator. The serum collected between the 
vitreous and the retina finds its way through the rent, and, passing down 
between the layer of rods and cones and the pigment layer, floats the retina 
forward (detachment of the retina). 

There is a condition in the fundus of the eye of myopes to which the 
term conus is given, which presents the appearance ophthalmoscopically of 
a white crescent, usually situated to the temporal side of the disc, or it 
appears as a white ring surrounding the nerve-head. It is customary to 
attribute this to atrophic changes in the chorioid surrounding the disc, 
brought about by the congestion and inflammation of the chorioid and 
sclera, leading to bulging back of the sclera, known as posterior staphyloma. 
That this conus (white crescent, or ring) is not the result of inflammation 
with subsequent atrophic changes of the chorioid, as is generally accepted, 
has been abundantly proven by the researches of Schnabel and others. It 
has been shown that the annular conus is due to the fact that the optic 
foramen (sclero-chorioidal canal) and the part of the optic nerve sur¬ 
rounded by it are unusually large, while the intraretinal portion of the 
nerve (the papilla) is smaller in diameter, because the fibres lose their 
perineural sheaths; hence a white zone is seen between the edge of the 
papilla and the peripheral portion of the connective tissue or of the cho- 
rioidal ring. So the white color does not come from the exposed sclera, 
but from the lamina cribrosa of the optic nerve. The layer of pigment 
epithelium begins at this ring. It lias not disappeared from the white zone, 
because it never existed in the part of the fundus in which the conus is 


ERRORS OF REFRACTION. 


711 


situated. When a posterior staphyloma (bulging back of the sclera) does 
coexist with conus, as is comparatively infrequent, the chorioid over the 
staphylomatous area is thinner than normal, but there is no marked circum¬ 
scribed atrophy around the papilla. 

The causation of the crescentic conus can be easily understood when it 
is remembered that the pial sheath of the optic nerve in every normal eye 
unites with the border of the elastic lamina of the chorioid, and, if this pait, 
of the chorioid does not extend to the edge of the chorioidal canal, the pial 
sheath in order to join it must extend across the anterior surface of the 
chorioid as far as the edge of the elastic lamina. Now, it has been shown 
that within the limits of the crescentic conus the elastic lamina and the 
chorio-capillaris are absent, and the posterior layers are thinner than 
normal. There is also very little, if any, pigment, and few or no vessels, 
while over the anterior surface of the conus is spread the pial sheath of the 
optic nerve, and in front of this lie the fibres of the optic nerve. Absence 
of the elastic lamina cannot be regarded as the result of atrophic change, 
because the pial sheath of the optic nerve stretches over the defect and 
unites with the elastic lamina at the periphery, just as in the normal eye. 
The anomalous position of the pial sheath and nerve-fibres form a constant 
anatomic feature of the crescentic conus; consequently the defect in the 
anterior layers of the chorioid must be regarded as the result of anomalous 
development, and not of disease. Every conus is congenital. 

The anatomic foundation of the crescentic conus in the myopic eye with 
posterior staphyloma is the same as the crescentic conus in the myopic eye of 
average length and form. An annular conus cannot develop from a cres¬ 
centic conus; neither can a crescentic one enlarge and become annular. 

The posterior staphyloma is a bulging backward of the sclera, forming 
a low, circumscribed protuberance with a circular base, or, if the distension 
is great, a conic elevation, situated between the outer side of the optic 
nerve and the tendon of the inferior oblique muscle. In others it may 
include the sclera surrounding the optic nerve; so that, instead of lying 
to one side, the optic nerve may form the summit of the staphyloma. The 
length of an eyeball with posterior staphyloma exceeds that of the longest 
emmetropic eyeball known. 

Schnabel has shown that posterior staphyloma occurs most extensively 
in eyes in which there is defective development of the chorioid, and an 
absence of the external fibre-layer of the sclera in the vicinity of the optic 
nerve, with resulting anomalous insertion of the dural sheath and conse¬ 
quent abnormal size and shape of the intervaginal space. He demonstrates 
that the increase in the intervaginal space is not due to the separation of 
the inner from the outer layers of the sclera; that the outer wall of the 
space is always covered by the arachnoid sheath, and is always surrounded 
by the two vaginal sheaths and the posterior surface of the inner layer of 
the sclera, just as in the normal eye, and never by the separated scleral 
lamellae. If the enlargement were due to stretching of the sclera, it would 


712 


MODERN OPHTHALMOLOGY. 


be most marked on the side of the optic nerve corresponding to the summit 
of the staphyloma and site of the crescentic conus; but the contrary is the 
rule, for the intervaginal space is much wider on the nasal than on the 
temporal side of the optic nerve. And, if the enlargement had been caused 
by the gradual distension of the sclera, the arachnoidal trabeculae on the 
inner surface of the dural sheath would be correspondingly more attenu¬ 
ated than in the normal eye, but the thickness of the trabeculae is much 
greater than normally. If the outer sheath had been forcibly separated 
from the inner it would be tense and its fasciculi would be stretched; in¬ 
stead of this the sheath is relaxed; its fasciculi are wavy and have 
the appearance of being too long. So Schnabel concludes that, “in view 
of the facts that posterior staphyloma is known to have existed in the early 
childhood of myopes of high degree, that no proof has yet been furnished 
that the sclera of eyes with such a condition ever possessed normal thick¬ 
ness and shape, that its development is not preceded by any disease of the 
eye, and, finally, that inflammation and increase of intra-ocular tension do 
not cause posterior staphyloma, but a different form of bulbar enlargement, 
it is certainly warrantable to conclude that the condition is an anomaly 
of development of the eye resulting from congenital peculiarities of texture 
in the parts of the chorioid and sclera surrounding the optic nerve.” Con¬ 
sequently if posterior staphyloma is a malformation, and not the result 
of disease, it cannot be acquired by eyes with normal membranes. And 
every eye with the posterior staphyloma of Scarpa is myopic; but only a 
very small number of myopic eyes have this type of staphyloma. He also 
claims that eyes primarily emmetropic or hypermetropic are in no danger 
of becoming affected with retinochorioiditis of the macula in consequence 
of acquired myopia. Only eyes with posterior staphyloma resulting from 
•congenital malformation have, in addition to excessive myopia, an especial 
predisposition to that grave disorder. 

In extreme cases of myopia there may be disseminated chorioiditis and 
chorioidal and retinal hemorrhages, with detachment of the chorioid. The 
crystalline lens becomes translucent or opaque. 

Symptoms.— Subjective Symptoms. —Persons myopic to the amount 
of 2 D. usually complain of not seeing distant objects clearly. In the higher 
degrees they can see objects distinctly only when held very close. They 
notice that the moon, the stars, or a street-light does not present a clear 
and well-defined outline. They appear as irregular, shining discs, which 
are much larger in diameter than they are to the normal eye, due to dif¬ 
fusion circles on the retina. The field of vision is always decreased, espe¬ 
cially noticeable when wearing the correcting lens. There ma'y be photo¬ 
phobia and photopsia. They complain of their eyes aching, and this is 
always aggravated by near work. This symptom is particularly trouble¬ 
some if there is also astigmatism present. 

The young myope will acquire distinct mental habits and peculiarities 
if the defect be not corrected with proper glasses. He will early learn to 


ERRORS OF REFRACTION. 


713 


avoid outdoor sports because of poor vision, and will cultivate a fondness 
for occupation suitable for his range. He will devote his time to constant 
study, winning the plaudits of his friends, which further increases the 
desire to attain higher ideals. He becomes retrospective and perverted in 
his taste. He will become brusque in his manner and unduly self-reliant. 
He has in general no correct idea of the impression which his person or his 
words make upon others, because he cannot appreciate the feelings and 
change of countenance of those he is addressing. Consequently he retains 
his original disposition, and is possessed of a peculiar freeness and too great 
self-confidence, or, what is still more rare, a more than ordinary self- 
consciousness, or bashfulness, is developed. Because of his superior knowl¬ 
edge gained by constant application to studies he arouses the jealousy and 
envy of his fellows, which in turn causes him to become rude, in order to 
hide a fear of each new face. He is uncongenial, and finally chooses some 
narrow groove having but feAv congenial spirits in it, and one that is con¬ 
stantly demanding increased study. Much more of what passes in the 
world escapes him than he is aware of, and with respect to a number of 
things his knowledge is less correct, because he fills up what is deficient 
through the operation of a brisk imagination. He is seldom practical and 
always is in search of the metaphysical. He sets a premium on physical 
deterioration, and possesses but little true intellectuality, his mentality being 
a mere precocity. 

Objective Symptoms. —Myopes have a tendency to approach closer 
than is necessary to the objects, and thus, particularly in sedentary work, to 
assume a stooping position. They prefer to read small print, and accustom 
themselves to small handwriting, avoiding as much as possible long lines, 
because by so doing they need not move the eyes and head so much as when 
they have broad pages and large letters before them. A certain awkward¬ 
ness is frequently manifested in their bearing and gait. The orbits are low, 
broad, and shallow in the young, increasing in height as the subject matures. 
During distant vision the eyelids are nipped together in order to see more 
distinctly by cutting off the diffusion circles. The brow is wrinkled. The 
nostrils are drawn up and the head is projected forward. They have a 
stupid appearance. The eyeballs are large and apparently protrude. 

There may be an apparent convergent strabismus when looking at a 
distance in high degrees of myopia, due to the fact that the visual line passes 
through the cornea to the outer side of the optic axis, and the eye must 
converge in order to bring the visual line to intersect the object. Angle 
gamma becomes negative. 

Myopia requires more convergence of the visual lines, because vision 
takes place close to the eye. Convergence is made difficult by the form of 
the eyeball impeding the movements, the small angles gamma and alpha, 
and the elongation of the muscles. The myopic eye, because of its static re¬ 
fraction, has no need of accommodation in order to see at a short distance; 
so the difficult convergence is not excited as in hypermetropia. Under these 


714 


MODERN OPHTHALMOLOGY. 


circumstances binocular vision is either not developed or at most is so only 
in a rudimentary way. Consequently, when there is a lacking of binocular 
vision and accommodation, the eyes almost always diverge. For these rea¬ 
sons myopia is the principal cause of divergent strabismus. At first the 
divergence is relative—that is, when looking at a distance the visual lines 
are properly directed; in close work only one eye is used, the other diverges. 
Later it becomes absolute: there is divergence of the visual lines in dis¬ 
tant as well as in near vision. 

In myopia the conjunctiva is usually congested. The anterior cham¬ 
ber is deep. The pupil is dilated and the iris is sluggish in reaction. 

Ophthalmoscopic Appearance. —Because of the shape of the eyeball 
in myopia, only a small portion of the fundus is seen without changing the 
position of the ophthalmoscope. It appears highly magnified and feebly 
illuminated. The optic nerve is apparently narrower in the horizontal 
meridian and longer in the vertical than in the emmetropic eye. This is 
due to the disc being placed more to the inside, the perpendicular to this sur¬ 
face being directed more strongly outward, and, this causing us to look 
obliquely on the nerve through the pupil, it appears shortened in the hori¬ 
zontal direction. In the young the nerve surface shows capillary hyperemia. 
There may be a conus,—a whitish area, crescentic in shape,—usually to the 
temporal side, or annular in shape, entirely surrounding the optic disc, and 
bounded by a pigment-ring. In cases of high myopia the Weiss reflex is 
present (Fig. 2, Plate XX). Retinal and chorioidal changes are often seen 
(Fig. 2, Plate XVII). 

In advanced cases the retinal vessels appear dragged, being straighter in 
their course. The main trunks diverge more at right angles. Seldom is 
there any change in the calibre of the vessels. There may be groups of 
irregular pigment splotches, white atrophic patches appearing in the 
chorioid, especially marked in the macular region. There is absorption of 
epithelial pigment throughout the fundus. In extreme cases there may be 
retinal hemorrhages, disorganization of the vitreous humor, and retinal 
and chorioidal detachment. The lens may become opaque. 

Diagnosis.—Myopia is indicated by the broad face, the protuberant 
eyeballs, divergent strabismus, indistinct distant vision, and good near 
vision. The near point of accommodation is closer to the eye than in 
emmetropia at the same age, and there is improvement of distant vision 
by a concave lens. Letters of double size are not read at double the 
distance. By means of the ophthalmoscope and the retinoscope the pres¬ 
ence of myopia becomes apparent. 

Treatment.—Myopia is a disease which can be prevented in a great 
measure, or at least much can be done to arrest its progress. 

As myopia is produced principally during adolescence, and is increased 
by continuance of near work, it is necessary to keep the child in vigorous 
health so that the eye-tissues can resist any reasonable sixain put upon 
them. Children recovering from any of the exhaustive acute diseases 


ERRORS OF REFRACTION. 


715 


should not be made to perform the same tasks as those in good health. 
They should be given sufficient nutritious food, fresh air, and exercise as 
well as general tonics. 

Those in feeble health or affected with chronic diseases should receive 
special attention. Young children should not have bright objects and toys 
held too near the eyes. They should not be sent to kindergarten at an 
age when they had better be enjoying the free air, playing games out of 
doors. Children are usually started to school entirely too early in life, often 
at four or five years of age. This period of life should be devoted solely 
to the building rip of all the tissues. The child should not be subjected to 
the destructive process necessitated by the so-called “play studies as pur¬ 
sued amid unhygienic surroundings. 

If all children could remain at home until they are eight years old, and 
then be sent to a school where some attention is paid to the general hygiene, 
myopia would rapidly disappear. 

In our schools attention should be directed toward securing proper 
lighting and ventilation. A northern exposure, with the light admitted 
from behind and over the pupil’s left shoulder, is to be preferred. One 
square foot of glass to five square feet of floor surface is sufficient if not 
shadowed by trees or houses. 

Stooping over work, with consequent damming of blood in the head, 
should be made unnecessary by having adjustable chairs and desks. The 
chairs should be just high enough to allow the feet to rest firmly on the 
floor. The desk-top should be sloping and arranged so that the body may 
be held erect, and the print or writing placed at a suitable distance from 
the eye. 

The great amount of writing, not only in school, but even at home, 
as required in some localities, should be protested against. School is the 
place for study. Children should be taught orally as much as possible; 
when writing is necessary it should be with pen and black ink. 

Text-books should be printed on unglazed paper. The type should be 
heavy faced and eight point or ten point in size. Two or two and one-half 
millimetres’ space should be between lines, on a double-column page. 

A systematic examination of the eyes of all children upon enteiing 
school should be insisted upon, and all refraction errors should be carefully 
estimated and corrected. 

Remedial. —If myopia becomes once established, we should endeavor 
to arrest its progress by the strictest care of the eyes and the employment of 
concave glasses, so as to render any necessary use more comfortable and 
less dangerous to the patient. 

In all young people in whom the accommodation is still active a ci^clo- 
pleoic should be used sufficiently strong to produce absolute loss of accommo¬ 
dative power, and especially so if there should be present any retinal haze 
and chorioidal woolliness. Repeated instillations on successive days should 
be made until the congestion of the chorioid and retina is diminished. As 


716 


MODERN OPHTHALMOLOGY. 


a rule, no correction should be made so long as there is congestion or inflam¬ 
mation of the eve. 

*/ 

A young subject, with good acuity of vision, a range of accommodation 
suitable to his age, and the balance of the external eye-muscles good, having 
a myopia under 5 D., may be allowed to wear the full correction habitually, 
both for near work and for distance. 

When the patient is older and the grade of myopia is higher, together 
with lowered acuteness of vision, the full correction should be lowered; 
or we should allow him to read uncorrected at his far point, wearing full 
correction only for distance. If his occupation makes it necessary to see 
distinctly objects lying farther off than his uncorrected far point, a partial 
correction should be given. In these cases the glass for near work is 
determined by finding the distance at which the work is to be done, and 
subtracting that number of dioptres from the strength of the distance 
glass. For example, supposing a myope of 4 D. wishes to see clearly at a 
distance of one metre (4 D. — 1 D. = 3 D.), a 3 D. glass would be required. 

In very high grades of myopia, with marked diminution of acuity of 
vision, it is best for the patient to relinquish all attempts at binocular vision 
with reading glasses and to use the eyes alternately. 

If there is weakness of the internal recti muscles amounting to ten 
or twelve degrees for distance, and a corresponding larger amount for near 
work, great relief can sometimes be obtained bv dividing one or both of the 
extcrni. Smaller degrees of insufficiency are satisfactorily treated by de¬ 
centring the glasses, so that their centres shall be farther apart than the 
centres of the pupils, that they may act as a prism with the base inward. 

When the myopia is 15 D. or more, the crystalline lens is sometimes 
removed, in appropriate cases, with improvement in vision and increase in 
the distance at which the eyes can be used for near work. Bruns, of New 
Orleans, performs discission of the lens in young subjects who have 12 or 
13 D. of myopia. 

ASTIGMATISM. 

Definition.—Astigmatism is that form of ametropia in which rays from 
one luminous point do not again unite into one point, or focus, on the retina. 

Defects in the antero-posterior diameter of the eyeball have been 
studied under the subjects of hypermetropia and myopia: hypermetropia, 
when the axis of the eyeball was too short; myopia, the axis being too long, 
both pertaining to the length of the eyeball. The defects in the dioptric 
system of the eye are: spheric aberration, chromatic aberration, and ir¬ 
regularity of radius of curvature. 

Spheric Aberration is due to the rays passing through the edge of a 
convex lens and those passing through the central portion not having the 
same focus. There is one principal focus for the more bent rays, those pass¬ 
ing through the periphery, and one for the less bent rays, or those passing 
through the central portion. This defect is almost corrected in the eye by 


ERRORS OF REFRACTION. 


717 


the iris, which cuts off the most peripheral rays, and also by the increase in 
density and curvature from the periphery toward the centre of the crystal¬ 
line lens. 

Chromatic Aberration. —In vacuum all kinds of light appear to 
travel at the same rate; but in most dioptric media they are unequally 
retarded. Commonly the light with short wave-lengths (near the violet end 
of the spectrum) is most retarded and most refracted. The dioptric system 



Fig. 403.—The cornea in emmetropia. Fig. 404.—Irregular astigmatism. 

of the eye also necessarily presents this chromatic aberration. Ordinarily, 
however, it scarcely interferes with the sharpness of vision. 

Irregularities of Radius of Curvature. —It is witn irregularities 
of radius of curvature of the lenses of the eye we are most interested at 
present. 

In studying hypermetropia and myopia it was assumed that* the diop¬ 
tric surfaces" of the eye curved equally in all parts and in all directions— 




Fig. 405.—Regular astigmatism. Fig. 406 .—Regular astigmatism. 

that they were small portions of spheric surfaces. But m reality they are 
not spheric in form. When even normal eyes are carefully examined, it will 
be found that the vertical meridian is usually more sharply curved than the 
horizontal. And the part of the dioptric surface in which this anomaly 
of curvature is most marked and constant is the cornea, producing regular 
astigmatism. In other words, the cornea, instead of being equally curved 
in all meridians, is more sharply curved in the vertical meridian and less 
curved in the horizontal. The difference in curvature is in different 

meridians (Fig. 405). 



















718 


MODERN OPHTHALMOLOGY. 


In irregular astigmatism there is a difference in curvature in different 
parts of the same meridian (Fig. 404). The seat of irregular astigmatism 
is usually in the lens. It is present in all human eyes, causing points or 
discs of light to appear to have irregular projections from them—to look 
“star-shaped.” When it is in the cornea, it is generally the result either 
of irregular contraction of cicatrizations from previous ulceration or of 
softening and stretching from some pathologic process, such as conic 
cornea. 

The seat of regular astigmatism is in the cornea, which has one 
meridian most sharply curved and another meridian at right angles to this 
with the longest radius of curvature. When the most sharply curved 
meridian, or meridian of greatest refraction, is vertical, or nearly so, it is 
termed astigmatism with the rule (Fig. 405). When the meridian of greatest 
refraction—most sharply curved—is in the horizontal direction, or nearly 
so, it is known as astigmatism against the rule (Fig. 406). 

Better to understand the effect such a cornea has in refracting rays of 
light, let us suppose a cone of waves falling upon a convex refracting surface 



Fig. 407.—Refraction of rays in regular astigmatism. 



with the shortest radius of curvature in the vertical, and the longest in the 
horizontal meridian. Through a central round opening (Fig. 407, A, 1, 2, 
3, Jf) let a cone of rays fall upon this surface. On account of the greater 
curve in the vertical direction (1-k) the rays will be turned up and down 
more than they will be turned in from the sides: they will converge faster 
vertically than horizontally, until at B they first form a horizontal oval, 
and then a horizontal band of light (C), called the first, or anterior, focal 
line. The line is equal in width to the unfocused horizontal rays. The 
vertical rays, crossing, diverge until at E their height equals the width of 
the separation of the horizontal rays, thus giving rise to a circle. The 
vertical rays still becoming progressively wider and the horizontal rays nar¬ 
rower, the image circle (E) is converted into a vertical oval as at F, until 
at G, where, the rays in the horizontal meridian having been brought to¬ 
gether, the vertical oval image is changed into a vertical line—the second , 
or posterior, focal line. ' The horizontal rays undergoing their crossing and 
the vertical rays becoming still more widely separated give width to an 
image at H, which becomes a vertical oval in shape or an ellipse with its 
long axis vertical. The interval (C-G) between these focal lines is called 
















ERRORS OF REFRACTION. 


719 


Sturm’s focal interval. The inequality of meridians producing regular 
astigmatism may take place either in a functionally emmetropic eye or in 
an hypermetropic or in a myopic one. 

When one meridian is emmetropic and the other is hypermetropic, the 
condition is called simple hypermetropic astigmatism—Ah (Fig. 408). 
In this form the focus of the one meridian, usually the vertical, is on the 
retina, and the other, the horizontal one, is behind the retina. 

When one meridian is emmetropic and the other is myopic, the condi¬ 
tion is known as simple myopic astigmatism—Am (Fig. 409). The focus 



Fig. 408.—Simple hypermetropic astigmatism. 

of the horizontal meridian is on the retina, and the focus of the vertical 
meridian is in front of the retina. 

When both of the principal meridians are hypermetropic, differing 
only in degree, it is termed compound hypermetropic astigmatism—H + 
Ah (Fig. 410). The focuses of both principal meridians are situated back of 
the retina, that of the vertical being closest. 

When both principal meridians are myopic, differing only in degree, 
it is known as compound myopic astigmatism—M + Am (Fig. 411). The 



Fig. 409.—Simple myopic astigmatism. 


focuses of both principal meridians are situated in front of the retina, that 
of the horizontal being closest. 

When one meridian is myopic and the other is hypermetropic, the con¬ 
dition is called mixed astigmatism—Amh or Ahm (fig. 412). The focus 
of the horizontal meridian is behind the retina, while that of the vertical lies 

in front of the retina. 

A difference of one millimetre between the meridians of greatest and 
least curvature of the cornea produces an astigmatism of six dioptres. 

Etiology.—Astigmatism is generally congenital and often is hereditary. 
It may also be acquired. The congenital astigmatism is principally regular 




720 


MODERN OPHTHALMOLOGY. 


and dependent upon asymmetry of the cornea. In the majority of cases it 
is present in both eyes, though it may vary in degree. Donders has found 
that abnormal astigmatism occurs far more frequently in hypermetropic 
eyes than in others. 

Acquired astigmatism is principally caused by inflammatory changes 
in the cornea, which lead to consecutive flattening of the cornea, and leave 
behind them opacities and cicatrices; it may also be caused by irregularity 
in the apposition of the edges of .the incision after the operation of extrac¬ 
tion of cataract and following iridectomy. It may likewise be caused by dis- 



V 


H 


Fig. 410.—Compound hypermetropic astigmatism. 


location of the crystalline lens, more particularly if it is obliquely displaced 
in the area of the pupil. It may be caused by swelling of the different 
sectors of the lens. 

Symptoms. —Subjective Symptoms.— The patient will complain of a 
sense of weariness and sleepiness and of pains in the eye, in the temple, and 
in the forehead, which at times shoot into the back of the head. As astig¬ 
matism is one of the most frequent causes of disturbance of the extra¬ 
ocular muscle-balance, there may be present great discomfort when looking 



Fig. 411.—Compound myopic astigmatism. 


at moving objects, vertigo, and difficulty in successively directing the gaze 
from one to another of different near points whose distances vary. The 
objects, before being fixed, appear indistinct or double. The patient is 
conscious of his eyes. 

In astigmatism constant distinct vision is impossible for either distant 
or near work, because of the overlapping of the images of the different 
points of an object causing a blur, or a wrong impression of its outline. 
So long as astigmatism does not essentially diminish the acuteness of vision 
it is called normal. It is abnormal so soon as disturbance occurs. If the 






ERRORS OF REFRACTION 


iv o 1 

( rC j 


eve is hypermetropic, distant horizontal lines will he seen more sharply than 
the vertical ones, because, the eyeball being short, the retina is nearer the 
anterior focal line, which is horizontal; while in the passive myopic eye 
vertical lines will be seen more distinctly than the horizontal ones, because 
the retina is nearer the vertical posterior focal line (Fig. 407). 

When, by strain of accommodation, the hypermetropic eye makes itself 
emmetropic, the vertical lines will be seen the most distinctly. A distant 
point of light will appear as a horizontal oval in hypermetropic eyes in a 
state of rest, and as a vertical oval in myopia and emmetropia. Of course, 
this is true only when the shortest curved meridian is the vertical. It is 

V 

impossible for the astigmatic eye to see simultaneously the strokes of letters 
which are at right angles to one another with absolute sharpness. Such a 
patient will make the characteristic mistakes in reading the Snellen test- 
card, mistaking E for P, Z for E, B for K, etc. The letters will have a 
streaked appearance. 

They will also assert that certain radiating lines in some one of the as¬ 
tigmatic charts are the most plainly seen. If a stenopeic slit be piaced 
before the eye so that the opening shall he parallel with the line best seen 



Fig. 412.—Mixed astigmatism. 


on the dial-plate, and if attention be directed to the letters, the visual 
acuity will be found to be less with the slit so situated than it would be 
were the slit placed at right angles to this direction. The blurring of the 
image also greatly diminishes the range over which the patient can read 
small type. Persons suffering with astigmatism often assert that they 
are able to see better at certain periods of the day than at others, because 
the hour-hand and the minute-hand on the graduated face of a clock are 
seen better either when in a horizontal or vertical position. 

Objective Symptoms. —The head is usually twisted to one side in 
accordance with the axes of the principal meridians of the astigmatism. In 
myopic astigmatism the eyelicls are usually half-nipped in the effort to 
obtain good distance vision, whereas in hypermetropic astigmatism the 
eyelids are widely separated. 

Ophthalmoscopic Appearance— In astigmatism the optic disc will 
appear more or less oval instead of round. In direct ophthalmoscopic ex¬ 
amination the enlargment is greatest in the meridian of greatest refraction, 
but the actual effect produced depends less upon the difference in the ap¬ 
parent length of the meridians of the disc than upon the contrast between 

46 



722 


MODERN OPHTHALMOLOGY. 


the sharp definition of all lines running parallel with one principal meridian 
and the indistinctness of those at right angles to this (Fig. 1, Plate IV). 

With the indirect method, the contrast between the vessels is less 
marked, but the oval shape of the disc is readily seen. When the object-lens 
is held close to the eye, the longest diameter corresponds to the meridian of 
least refraction; as the lens is withdrawn from the eye, the meridian of 
greatest refraction elongates, either actually or relatively to the other 
meridian, so that the disc becomes circular and then elongated in the other 
direction. In high myopia the nerve was described as presenting an oval 
appearance due to its being viewed obliquely. 

Diagnosis.—The presence of astigmatism may be detennined by the 
characteristic mistakes in reading Snellens type or by the appearance of the 
astigmatic chart. There are a great many different forms of these charts, 
but the one most used is the ordinary “clock-dial” (Fig. 413), which con- 



Fig. 413. 


sists of a white card with peripheral Roman characters corresponding to 
the characters on the face of a clock. From those figures a series of three 
parallel black lines, with interspaces of the same width as the lines, cross 
from XII to VI, III to IX, etc. The card is placed on a horizontal line 
perpendicular to the patient’s eyes, at the usual distance, one eye being 
tried at a time. The patient is requested to state which is the clearest, 
the blackest, and the most distinct line. The meridian of the eye which 
corresponds to the dark lines selected is the meridian of astigmatism. The 
axis of the cylinder will be opposite to the meridian of the dark lines. 
When the astigmatism is of low degree it may not be recognized by this 
means until the spheric correction is placed before the eye or after a 
cycloplegic has been instilled. 

The presence of astigmatism may also be diagnosed by means of the 
stenopeic slit, Placido’s disc, the perforated disc, Pray’s letters, chromo¬ 
aberration test, the ophthalmometer, ophthalmoscope, retinoscope, or by 
the use of cylindric lenses. If the acuity of vision is diminished and can- 











ERRORS OF REFRACTION. 


723 


not bo improved by spheric lenses and there is no organic disease, it usually 
signifies the presence of astigmatism. 

Irregular Astigmatism is determined by the lowered acuity of vision; 
monocular diplopia and polyopia; the apparent deformity of objects looked 
at; and by the ophthalmoscopic appearance of the fundus oculi, the details 
of which appear elongated, compressed, or stretched, changing in shape as 
it is viewed through different parts of the cornea. If caused by conic 
cornea, the ophthalmoscope will show a circular shadow surrounding the 
central part of the red from the fundus. The keratoscope may also be 
used. Images reflected from the cornea are irregular and distorted. 

Treatment.—Astigmatism should be corrected whenever it produces 
symptoms, no matter how small the amount of error. In the weak, sickly, 
and neurasthenic, asthenopia is produced by degrees of astigmatism which 
would pass unnoticed in the healthy and vigorous individual. 

As to the ordering of glasses for the different forms of astigmatism, 
the same may be said as in the other refractive errors: there can be no fixed 
rule to follow blindly. The examiner must exercise his judgment. But in 
order to have some guide we may say that in mixed astigmatism and myopic 
astigmatism the full correction is ordered for distance. In myopic astig¬ 
matism the spheric lens may he made weaker for near work. 

In correcting compound hypermetropic astigmatism the cylinder should 
he ordered full, combined with as much of the sphere, correcting the hyper- 
metropia, as is necessary to secure normal muscle-balance for both distance 
and near. In many cases, especially if the astigmatism be of high degree, 
or if the axes of the cylindric lenses are oblique and asymmetrical, the dis¬ 
tortion of objects produced by the correction of the error is so annoying 
to the patient that it may be necessary to give only a partial correction, and 
gradually increase the strength of the lens until the full amount that was 
found during the cycloplegic examination has been reached. At times, 
especially in old subjects, in order to make the patient comfortable it may 
be necessary to omit the cylindric corrections. 

As a rule, in making the post-cycloplegic test in hypermetropic astig¬ 
matism the full correction should be placed before the eye, the strength and 
axis of the cylindric lens not being changed, but the spheric lens may be 
weakened until full acuity of vision is obtained, as in the treatment of 
hypermetropia. In a few rare cases the post-cycloplegic axis must be the 
permanent one that is used. In order to give good vision and restore 
muscle-balance it may be necessary to give one correction for distance and 
another for near work. 

Irregular Astigmatism requires treatment only when the vision is 
very much reduced as the result of irregularities of the corneal surface from 
ulcers and cicatrices. It may be possible to find one meridian of regular 
curvature and by means of a cylindric lens vision may be improved. Vision 
is sometimes improved by stenopeic spectacles. An iridectomy may be use¬ 
ful by displacing the pupil toward a more regular portion of the cornea. 



724 


MODERN OPHTHALMOLOGY. 


APHAKIA. 

Definition.—By aphakia we mean an absence of the crystalline lens 
from the pupillary area. If the lens has by luxation or depression en¬ 
tirely disappeared from the plane of the pupil, even though it be still pres¬ 
ent in the eye, the condition is termed aphakia. Partial luxation, causing 
the equator of the lens to correspond to the plane of the pupil, is not 
aphakia. 

When the crystalline lens is absent the power of accommodation is 
abolished. The lens, when in normal position, possesses an optical strength 
of about 11 D. Absence of the lens, therefore, in an eye previously emme¬ 
tropic would create an hvpermetropia of 11 D. The only eyes that do not 
become hypermetropic upon losing the lens are those which are myopic 11 
D. or more. 

It is claimed by some that in the lensless eye there is still a part of 
accommodation which is dependent upon the action of the ciliary muscle 
in diminishing the radius of curvature of the cornea. The apparent accom¬ 
modation found in some cases after cataract operation is, however, probably 
due either to a slight shifting of the correcting lens, causing an increase in 
the distance between the glass and the eye, or to a narrowing of the pupil 
in the effort to see near objects, with consequent diminution of the circles 
of diffusion. 

Etiology.—Aphakia may be congenital, but it is most frequently pro¬ 
duced as a consequence of the resorption of the lens, either accidental or as 
the result of operation, and also as the result of the operation of extraction 
of a cataractous lens. 

Symptoms.—The aphakic eye can see clearly only at the distance for 
which it is adapted by the length of its axis and the curvature of its cornea, 
with or without the aid of spectacles. The acuteness of vision is usually 
imperfect in aphakia following cataract extraction, due to turbidity of the 
surface of the pupil from a slight deposit on the inner surface of the capsule 
of the lens. There is generally an increase in the depth of the anterior 
chamber. The iris, deprived of its support, no longer bulges forward, as 
in the healthy eye. There is a certain degree of trembling (iridodonesis) 
with each sudden movement of the eye, unless the iris be rigid or adherent 
to the remains of the lens or its capsule. But none of these phenomena is 
characteristic. 

The most decisive symptom of aphakia is the absence of the crystal¬ 
line reflexes of Purkinje’s images. In addition, in the normal eye the 
sectors and the direction of the fibres of the crystalline lens are easily seen 
on lateral illumination with light concentrated by a lens, particularly with 
the aid of a strong magnifying glass. Where these are wanting we may 
infer absence of the lens. Finally, a very high degree of hypermetropia, 
and a considerably weaker refraction in one eye than in the other, in con¬ 
nection with the form of the eye, render probable the existence of aphakia. 


ERRORS OF REFRACTION. 


Diagnosis.—Absence of the lens is to be diagnosed accurately only by 
observing that the two images of Purkinje reflected from the lens are not 
present, and also by the inability to see the sectors and direction of the 
fibres of the lens on lateral illumination. It may also be suspected by the 
deep anterior chamber, trembling of the iris with sudden movement of the 
eye, and when after a blow or knock upon the eye the acuity of vision has 
suddenly diminished., associated with a very much higher hypermetropia 
than the fellow-eye without very manifest disturbances in the organ, and 
by absence of accommodation. 

Treatment.—Aphakia following removal of the crystalline lens causes 
an hypermetropia of about 11 D. in the emmetropic eye. If the eye has 
been previously myopic, the hypermetropia will be reduced. The hyper¬ 
metropia thus produced can be usually corrected for distance vision by a 
-f 10 D. glass. A glass having a focus of 16 to 25 centimetres added to the 
above will be required for near work. Astigmatism should be sought for 
and should be corrected. 


PRESBYOPIA. 

Definition.—Presbyopia is the condition of any eye in which, as the 
result of age, the range of accommodation is diminished and the punctum 
proximum is removed beyond twenty-two centimetres (eight inches). 

Etiology.—At birth the lens is soft, elastic, and perfectly transparent, 
and so nearly of the same index of refraction as the aqueous humor that 
in children it is often difficult and sometimes is impossible to demonstrate 
its presence by means of oblique light. It rapidly becomes more dense, 
especially the nucleus and the parts immediately surrounding it, until, after 
twenty years of age, it acquires a faint straw-yellow color, even though 
the lens is transparent, until it has become almost of an amber color, the 
nucleus increasing at the expense of the cortical substance. The result 
of this is a diminution in the elasticity; so that, even in early youth, the 
lens is less capable of swelling and changing its curvature than it was in 
infancy. However energetic the contraction of the ciliary muscle may be, 
and however complete the relaxation of the zonula of Zinn, the form of the 
lens varies less and less under their influence; and, with its convexity, its 
refraction, during the extreme effort of accommodation, differs less and 
less from that which it possesses when the eyes are at rest. In other words, 
the range of accommodation diminishes as age advances. Associated with 
the progressive increase in the rigidity of the lens there is late in life weak¬ 
ness or even atrophy of the ciliary muscle, which is an important factor in 

the causation of presbyopia. 

The range of accommodation diminishes scarcely, if at all, more rapidly 
from much close work than it does in agriculturists, sailors, and others 
who, for the most part, look at distant objects. The same is true of the 
frequent use of the microscope or a magnifying glass as is required in the 
work of engravers and watchmakers; the regular course of the range of 


726 


MODERN OPHTHALMOLOGY. * 


accommodation is maintained despite much or little tension. In eyes pre¬ 
disposed to myopia much near work easily renders them more myopic, but 
it has no influence on the range of accommodation. There are morbid 
conditions which cause the range of accommodation, and sometimes also 
the amount of refraction, to diminish more rapidly than usual: general 
debility, the result of exhausting diseases, and premature old age. 

If a person has quickly and repeatedly to strengthen his glasses, we 
should suspect the presence of glaucoma. The commencement of cataract 
also appears to hasten presbyopia, probably through more rapid hardening 
of the crystalline lens interfering with its mutability of form. Paresis and 
paralysis of accommodation interferes prematurely with the vision of near 
objects. Any disease that interferes with the nutrition of the lens will 
eventually limit its power to become more convex during accommodative 
effort. Also any disease which weakens the ciliary r muscle hastens the ad¬ 
vent of presbyopia. 

Symptoms.—The actual fall of the accommodative power with the age 
and the range of accommodation for each period of life is very well demon¬ 
strated by Donders’s diagram (Pig. 411). The figures on the left give the 
respective distances for which the eye can be accommodated, those below 
infinity being so marked as to express the distance at which the convergent 
rays, for which the eye is adapted in old age, would come to a focus behind 
its nodal point. The black curved line indicates the actual position of the 
near point at each time of life, as specified in numbers at the top of the 
table. The vertical lines joining the near and the far points give the entire 
range of accommodation. On the left-hand side are the equivalents in 
dioptres. 

It is for emmet.ropia that this scheme was originally drawn. Hence 
the line commences at the zero-point of the division. It is straight and 
coincident with the zero-line until just before reaching the vertical line 
corresponding with the age 55 years, where it commences to descend 
and enters the negative portion of the diagram. The position of the punc¬ 
tual remotum does not change until the age of 55 years, when it changes 
its position and passes from infinity to the rear of the eye. The emmetrope 
commences to get hypermetropic, the myope notices a decrease in the myopia 
proportionate with the recession of his near point, and the hypermetrope is 
conscious of an annoying increase in his hypermetropia. Emmetropia and 
ametropia, without regard to the degree of the latter, are alike subject to 
the laws governing the range of accommodation. 

If we consider presbyopia as commencing when the near point is re¬ 
moved beyond 22 centimetres, which is equal to 4.5 dioptres of positive 
refraction, then it will be seen by referring to Donders’s diagram (Fig. 414) 
that a myope of over 7 dioptres can never become presbyopic, for even with¬ 
out accommodation they see at 142 millimetres up to the age of 50 years, 
and up to the age of 64 by adding to it their dynamic refraction. Even at 
the age of 80, when there is no longer any dynamic refraction and the static 


ERRORS OF REFRACTION. 


has diminished 2.5 dioptres, they still have remaining 7 — 2.5 = 4.5 diop¬ 
tres with which to see at the required distance of 22 centimetres (8 inches). 
Myopes of lower degree than 7 dioptres become presbyopic, but earlier or 
later, according to the degree of their myopia. 

The emmetrope becomes presbyopic at 40 years of age. The diagram 
shows that at this age the punctum proximum is at 4.5 dioptres. From this 


AGE 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 



time on the amount of positive refraction which the eye needs in order to 
have the requisite 4.5 dioptres must be supplied by convex lenses. 

The hypermetrope becomes presbyopic sooner in proportion as his hy- 
permetropia is of higher degree. Thus, a hypermetrope of 4 dioptres is 
presbyopic at the age of 25 years, because, in order to attain the required 
4.5 dioptres of refraction, he must have 4 -j- 4.5 = 8.5 dioptres of dynamic 









































































728 


MODERN OPHTHALMOLOGY. 


refraction, and it is only up to the age of 25 that his accommodation is so 
strong as that (Fig. 414). When the hypermetropia is of higher degree, 
presbyopia manifests itself still earlier. 

Thus it is seen that if we were to restrict the term presbyopia to the 
position of the uncorrected near point, the meaning of the word would be 
contradictory, for, as has been shown, the higher the degree of hyperme¬ 
tropia, the earlier in life would the eye become presbyopic, which term must 
lead to considerable confusion. But the hypermetrope is presbyopic only 
so soon as, in the use of glasses which neutralize the hypermetropia, the 
near point lies farther from the eye than 22 centimetres (8 inches). 

The following table shows the near point and amplitude of accommo- 


d at ion 

in dioptres from 10 to 75 years, 

with 5-year 

intervals:— 


Year. 

Near Point. 

Dioptres. 

Year. 

Near Point. 

Dioptres. 

10 

7 cm. 

14 

45. . 


3.5 

15.... .. 


12 

50. 

40 

2.5 

20. 

. 10 

10 

55. 

55 

1.75 

25. . 

12 

8.5 

60. 

. . 100 

1 

30. 

. 14 

7 

65. 

. . 133 

0.75 

35. 

. 18 

5.5 

70. 

. . 400 

0.25 

40. 

22 “ 

4.5 

75. 




At first, of course, no inconvenience is experienced from this gradual 
recession of the near point; we do not, in fact, notice it until the distance 
is so considerable that we cannot easily distinguish small objects. Seldom 
do we hear that close reading and work cause fatigue. The complaint is 
rather that vision is not accurate; the letters are not easily distinguished; 
numbers are confounded; a stroke is seen double. If we place small print 
in the hand of such a presbyopic person, he begins by holding the book too 
close to his eye, and does not distinguish; he subsequently very pathogno- 
monically moves the book forward and the head backward, seeks a bright 
light, complaining of - even ordinary print. Often, he may either hold 
the letters between the light and himself or so place them that a strong 
light shall fall both on the eye and on the printed joage, not so much because 
the retinal images are by it more strongly illuminated, but because the pupil 
contracts; the circles of diffusion thereby become smaller and the retinal 
images less diffused. Therefore, also, the individual first perceives some 
difficulty in twilight, unless it be particularly strong. Inconvenience would 
have arisen even earlier, if the diminution of accommodation had not been 
accompanied with diminution of the diameter of the pupil. Thus, also, 
the small pupil of the old man makes the loss of the power of accommoda¬ 
tion lighter to him: to this he is indebted for the fact that, even for dis¬ 
tances for which he is not accurately accommodated, he still distinguishes 
tolerably well. 

In full daylight in the open air a person can often, even in advanced 
presbyopia, read ordinary type, and this always succeeds on looking through 
a smali opening. 
















ERRORS OF REFRACTION. 


729 


Diagnosis. Presbyopia is indicated by the age of the patient; the 
position of the near point; history of good distance vision and inability to 
see near small objects distinctly, being obliged to remove them farther from 
the e}e, or even to seek a bright light, and to hold reading matter at an un¬ 
comfortable distance. 

Treatment. Having determined from the tests given that the symp¬ 
toms complained of by the patient are due to a weakening accommodative 
power, which prevents the patient using his eyes with comfort for near 
work at a comfortable distance, this deficiency must be made up by sub¬ 
stituting a convex glass of sufficient strength which will enable him to use 
his eyes with comfort and safety at the necessary distance. 

As a rule, in the emmetropic eye the glass necessary to enable the patient 
to work comfortably at thirty-three centimetres (thirteen inches) will be 
a + 1 H- spheric lens at the age of 45 years, a -f- 2 sphere at 50 years of age, 
a + 2.50 sphere at 55 years, and a + 3 sphere at 60 years or over. This 
rule, as has been said, is applicable only to the emmetropic eye. An y 
existing ametropia must first be very carefully sought after and corrected, 
to which correction the above is added. For example, if there is an hyper- 
metropia of 2 D. at 45 years of age, there should be a -f- 1 sphere added, 
which would make the correction a -f 3 D. sphere. 

All presbyopic hypermetropes should have a glass which represents the 
sum of the presbyopia and the hvpermetropia. 

In myopia the amount may be considered the equivalent to a convex 
glass for the correction of presbyopia; consequently a patient having a 
myopia of 1 D. would not require any glass for near work until he had 
reached the age of 50 years, when he would require a-f 1 sphere. A myope 
of 3 or 4 D. never becomes presbyopic, inasmuch as he will always be able 
to read at his far point. In higher degrees of myopia it will be necessary 
to weaken the full correction until the patient can see near objects clearly. 
It will be found impossible to force the patient to read at thirty-three cen¬ 
timetres, because of the reduction of acuity of vision, which compels him 
to hold print closer to the eye to enable him to see clearly. Frequently high 
myopes will read more comfortably without any glass, holding the print 
close and using only one eye at a time. 

In simple myopic astigmatism a convex cylinder of a strength equal to 
the concave cylinder with its axis reversed will enable the patient to read. 
For instance, if he requires a — 1 cyl. (axis, 180°) for distance, a -f- 1 cyl. 
(axis, 90°) will be required for near vision at 45 years of age. At 50 years 
of age a + 1 sph. 3 + 1 cyl. (axis, 90°), and at 60 years of age a -)- 2 sph. 
3 + 1 cyl- (axis, 90°) will be necessary. 

Compound myopic astigmatism amounting to several dioptres will re¬ 
quire a reduction of the spheres only, leaving the cylinder unchanged. In 
lower degrees of compound myopic astigmatism the combination would be 
different; for instance, if distance vision required — 0.50 sph. 3 — 1 cyl. 
(axis, 180°) at 45 years of age, he would require — 0.50 sph. 3 + 1 cyl. 


730 


MODERN OPHTHALMOLOGY. 


(axis. 90°) ; at 50 years his requirement would be -f- 0.50 sph. 3 + 1 cyl. 
(axis, 90°). 

In mixed astigmatism the combination — 1 sph. 3 + 2 cvl. ( ax is> 
90°) for distance will require at 45 years of age -|- 2 cyl. (axis, 90°); at 
50 years, -(- 1 sph. 3 + 2 cyl. (axis, 90°). 

It is best to place the distance and near correction in separate frames 
so that the optical centres of the glasses can be made to correspond to the 
visual lines when looking at a distance and when using the eyes for near 
work; otherwise there would be considerable prismatic deviation and dis¬ 
tortion of objects produced by the cylindric lenses. 

The rule of adding 1, 2, or 3 dioptres to the ametropic correction ac¬ 
cording to the age of the patient will answer when the patient wishes to 
use his eyes at thirty-three centimetres, but, as in the case of bookkeepers, 
musicians, carpenters, and those persons folloAving any occupation in which 
it will require a longer range, as well as in those in which the object must 
be held closer, as with the engraver, goldsmith, and embroiderer, the dis¬ 
tance at which the work is placed must be ascertained, and a glass should 
be given whose focal length will be somewhat greater than the distance 
required. 

Great care must be taken not to give too strong a glass for the correc¬ 
tion of presbyopia. A strong glass enables the eye to see distinctly without 
accommodative effort, but at a distance which makes considerable demand 
on the convergence. It is better to use the weakest glass that gives the re¬ 
quired vision and have the optical centres set a little closer together than 
the centres of the pupils, the lenses thus acting as weak prisms with their 
bases inward, thereby diminishing the convergence necessary for binocular 
fixation, while they lessen the strain on the accommodation and bring the 
near point closer. 

ANTIMETROPIA AND ANISOMETROPIA. 

Definition.— Antimetropia means a different kind of refraction in the 
two eyes. It does not have reference to the amount of the error of refrac¬ 
tion. One eye may be emmetropic, hypermetropic, or myopic (hypometro- 
pic), while the other eye is hypermetropic, myopic (hypometropic), or 
emmetropic. 

Anisometropia means an unequal amount or degree of the same kind 
of refraction error in the two eyes. According to this definition, both 
eyes must be hypermetropic, myopic (hypometropic), or astigmatic, but 
one is more so than the other. 

Etiology.—Antimetropia or anisometropia may be congenital or ac¬ 
quired. The difference in the development of the two eyes is usually 
associated with a similar inequality between the corresponding orbits and 
the two halves of the head. At the side where the strongest refraction 
occurs the orbit is situated closer to the median line, and its surrounding 
edges are placed more forward. But the connection is not absolute, for 


ERRORS OF REFRACTION. 


731 


the orbits may differ in form and position, while the two eyes may he 
emmetropic. It may even he that the less refracting eye corresponds to 
the more prominent side of the forehead, the more projecting cheek-hone, 
and the larger side of the chin. Acquired antimetropia is limited chiefly 
to aphakia and to loss of accommodation in one eye. 

It is hardly possible that one eye may become myopic in consequence 
of its exclusive employment for near vision, while the other remains hyper¬ 
metropic, for the organ which does not participate in vision partakes of 
the fatigue of its mate, and an eye excluded from vision and deviated may 
become more staphylomatous and more myopic than its fellow which is 
constantly active. The congenital predisposition to myopia is lacking in 
the active eye which has remained hypermetropic, while the other has 
become myopic. 

Vision in antimetropia or anisometropia may be possible in three 
ways:— 

1. Binocular vision. An antimetrope or anisometrope almost always 
makes the same effort of accommodation on both sides. He combines the 
distinct retinal image of the stronger eye with the diffuse image of the 
other. The difference between the two retinal images may be great (— 6 
D. or more) without their ceasing to be united in one stereoscopic impres¬ 
sion. But we usually abstract from the one eye more easily than from the 
other. 

2. Vision with each of the two eyes alternately. This occurs espe¬ 
cially when one of them is emmetropic and the other is moderately myopic, 
and when each possesses a good visual acuteness. The former is used in 
distant vision and the other for seeing near at hand. 

3. Constant exclusion of the one eye, and always the same eye. This is 
especially the case when not alone the refraction, but also the visual acute¬ 
ness, of the two eyes is very different. There is then usually divergence if 
myopic, or convergence if hypermetropic. 

In the deviation inward the field of vision is diminished in the deviated 
eye and falls more over the other. This may produce confusion; therefore 
we mentally neglect the impressions received in the deviated eye, which 
consequently becomes amblyopic. In the deviation outward only a small 
portion of the field of vision is common. Therefore the power of vision is 
generally tolerably satisfactorily maintained, even though the eye is not 
used. 

Diagnosis.—The presence of antimetropia or of anisometropia may be 
determined by the facial asymmetry, by the difference of the position of 
the near and far point of the two eyes, and by the same tests as are applied 
to errors of refraction previously mentioned. 

Treatment.—In antimetropia with binocular vision, if one of the eyes 
is emmetropic and the other is ametropic, glasses should not be given for 
distance vision unless the ametropic eye has the better vision. For near 
work the patient should be given for both eyes the glass required by the 





732 


MODERN OPHTHALMOLOGY. 


emmetropic eye. Antimetropia is never corrected by unequal action of 
the ciliary muscle. 

If both eyes are ametropic and the difference is not greater than 1.50 
D., with good vision in both eyes, we may equalize the refraction by giving 
the glasses which correct each eye. If the ametropia is greater than 1.50 D., 
we find which is the working eye and correct the ametropia, the same amount 
being given to the other eye. 

If there is antimetropia without binocular vision, one eye being 
myopic 4 D. and the other emmetropic, the patient will use the emmetropic 
eye for distance and the myopic eye for near work, never having to wear 
glasses. 

If both eyes are myopic we should give each the correcting glass of the 
weaker eye. 

If both eyes are hypermetropic, and the more hypermetropic one is used 
for distance vision, each eye is given the correcting glass of the strongest 
hypermetropia. If there is an hypermetropia of 4 D. in one eye and 1 D. 
in the other, we may order -f4D. for each eye. The first one will be used 
for distance and the other for near vision. 

In antimetropia in which one eye is used exclusively it is only neces¬ 
sary to correct this one. The other should receive some form of exercise 
after having its refractive error corrected so as to retain some vision in case 
of accident to the good eye. 

The treatment for antimetropia due to paralysis of accommodation 
will be found elsewhere in this book. 

The Trial-case is a box containing the lenses which are used in the 
examination of the refraction of the eye. These include convex and con¬ 
cave spheric and convex and concave cylindric lenses, which are in pairs; 
prisms, plane and colored glasses, opaque discs, and a stenopeic disc. A 
trial-frame and other accessories complete the equipment. The spheric 
lenses vary in strength from 0.12 D. to 20 D., and the cylindric lenses from 
0.12 D. to 6 or 8 D. The interval between the lenses should be 0.12 D. 
for the lower strengths and 0.25 or 0.50 D. for the higher ones. 


CHAPTER XXII. 

THE OCULAR MANIFESTATIONS OF NERVOUS DISEASES. 


By J. C. KNIPE, M.D., of Philadelphia, 

Ophthalmologist to the Jewish Hospital. 

Various external conditions of the eye are indicative of nervous dis¬ 
eases. Subjectively, there may be pain or anesthesia. Peripheral irritation 
of the sensory nerves will cause neuralgias, and paralysis of the same 
nerves will cause anesthesia. The latter condition of the cornea may be 
present in paralysis of the fifth nerve, which may later cause a vasomotor 
disturbance, and a neuroparalytic keratitis (Knies). Hysteric anesthesia 
of the cornea is not followed by keratitis. 

Pressure on or injury to nerves, inflammation, or degeneration of the 
nerve-fibres or of the cells of their nuclei may cause paralysis of any of the 
ocular muscles. The lesion may be orbital or cranial, and may be due to 
meningitis, tumor, aneurism, fracture, hemorrhage, embolism, thrombosis, 
abscess, hydrocephalus, changes in the blood-pressure, edema, softening, and 
lithiasis. In congenital paralysis the muscle may be absent: e.g congenital 
ptosis from absence of the levator palpebrae superioris. 

If all the eye-muscles (except the superior oblique and the external 
rectus), together with the levator palpebrae superioris and the iris and ciliary 
muscles, are paralyzed, the third (motor oculi) nerve is involved. The 
superior oblique and the external rectus depend, respectively, on the fourth 
and sixth nerves. 

Conjugate lateral paralysis, in which the eyes fail to move conjointly 
to the right or left, is due to a lesion in the centre for associated movements, 
the situation of which has not been positively determined. An irritation 
of the cortical region of the fifth nerve will produce conjugate movements 
to the opposite side, and it has been shown that destructive lesions of the 
cortex will produce a paralysis of associated movements to the opposite side. 
The antagonists draw the eyes away from the paralyzed side of the body, but 
toward the side of the brain lesion. If the lesion is in the pons, the oppo¬ 
site side of the body is paralyzed, but by the involvement of the nucleus of 
the sixth nerve—which is in close proximity on the same side of the pons— 
the external rectus muscle of the same side is paralyzed, and the eye turns in 
the opposite direction—toward the paralyzed side of the body. Irritative 
lesions in the same situations would have the opposite effect. 

Ptosis (paralysis of the levator palpebrae superioris) is usually part of 
the paralysis of the third nerve. It may exist independently by involve¬ 
ment of only a branch of that nerve. A lesion of the cortical trigeminal 
(fifth) nerve seems to produce paralysis of the opposite levator palpebrae 
superioris (Knies). It may also exist independently on the same side as 

(733) 


734 


MODERN OPHTHALMOLOGY. 


the lesion in disease of the pons, associated at times with conjugate paralysis. 
Ptosis may also exist independently in crossed paralysis with a lesion in the 
crus cerebri. Paralysis of a portion of the third nerve, particularly the 
branch to the levator palpebrae superioris, may he caused by a lesion of the 
cerebral peduncle (Swanzy). 

Fourtli-nerve 'paralysis is rarely found alone, and is usually produced 
by disease at the base of the brain, such as meningitis or pressure in the 
valve of Vieussens. (Pfungen.) 

Paralysis of the sixth nerve is more frequent as a distant symptom than 
any other (Swanzy), particularly in lesions of the cerebellum (Wernicke). 
This is said by Gowers to be due to the lengthened course of the sixth 
nerve over the pons, making it more liable to pressure. Fracture at the 
apex of the petrosal part of the temporal bone may produce it. 

Paralysis caused by basal lesions in the neighborhood of the pons, the 
ventricles, and the aqueduct of Sylvius can be distinguished from nuclear 
paralysis by the association in the former of graver symptoms such as 
hemiplegia, vomiting, headache, optic neuritis, and hemianopsia. 

Irritative lesions, in contradistinction to destructive lesions, may cause 
muscular spasm. Spasmodic movements of the levator or of a rectus muscle 
are common. The orbiculares may be spasmodically contracted in hysteria, 
simulating double ptosis, but differentiated by a subjective muscle resistance 
which is not present in true paralytic ptosis. A temporary ptosis or diplopia 
is a symptom which will cause strong suspicion of tabes or syphilis. 

Nystagmus is another spasmodic condition of the ocular muscles. It 
is characterized by rhythmic oscillations of the eyeballs. It is almost always 
present in insular sclerosis and Friedreich’s hereditary ataxia, and may be 
a symptom of meningitis, cerebral hemorrhage, and tumors, or an hysteric 
manifestation. 

CONDITIONS OF THE PUPIL. 

Miosis.—Caused by an irritation of the pupil-contracting centre. This 
symptom is present in the early stages of inflammatory affections of the 
brain, in cerebrospinal and tubercular meningitis, and early in tumors and 
apoplexy. Berthold pointed out that, in this, apoplexy differed from 
embolus, in which the pupils are not affected. It is also noticed in the 
beginning of hysteric and epileptic attacks, in tobacco-amblyopia, and in 
watchmakers and other habitual near workers. 

Miosis caused by paralysis of the cervical sympathetic or the pupil- 
dilating centre occurs in injury to the cord, pressure of an aneurism or of 
enlarged glands, and in lesions of the spinal cord, as in locomotor ataxia. 
It occurs also in general paralysis of the insane. 

Mydriasis caused by an irritation of the pupil-dilating centre, is present 
early in inflammation, anemia, or tumor of the cervical cord. It may also 
occur in intestinal irritation, mental excitement, early in acute mania, and 
in general paralysis of the insane. 

Mydriasis caused by paralysis of the pupil-contracting centre occurs 


THE OCULAR MANIFESTATIONS OF NERVOUS DISEASES. 


i oo 


from pressure on the third nerve at the base of the brain or in the orbit. 
It also occurs in glaucoma, in the later stages of general paralysis of the 
insane, and in optic-nerve atrophy in which there is no light-stimulus. 


L.F. B. F. 



Fig. 415.—Diagram of the visual tract. 

O O 

R. F, Right visual field. L. F, Left visual field. N., Nasal side. T., Temporal side. 

R. R. Right retina. L. R., Left retina. 0. C., Optic chiasma. 0. JV., Optic nerve. 0. T., 

Optic tract. C. Q., Corpora quadrigemina. EX. G. B., External geniculate body. 1. 0., 
Thalamus opticus. C. C\, Corpus callosum. 

THE VISUAL TRACT. 

The visual tract (Fig. 415) begins with the rods and cones of the 
retina and the three bundles of optic-nerve fibres making up the papilla and 
the optic nerve. This extends back to the chiasma, in which the inner 









736 


MODERN OPHTHALMOLOGY. 


bundle of each nerve decussates and joins the outer bundle of the opposite 
nerve and becomes the optic tract. The tract extends around the crus 
cerebri, and ends in the external and internal geniculate bodies, and the 
pulvinar on the posterior part of the optic thalamus. Some of the fibres 
extend to the corpora quadrigemina. These parts are called the primary 
optic centres, and from them the visual radiations, or fibres of Gratiolet, 
extend backward through the internal capsule to the cortex of the cuneus 
and the superior occipito-temporal convolution. Henschen believes from 
investigations that the centre of vision is in the middle of the calcarine fis¬ 
sure. Each hemisphere is in anatomic relation with the corresponding lat¬ 
eral half of each retina. At the macula lutea these halves seem to overlap, 
making a double nerve-supply, by which means central vision is preserved 
in cases of a destructive lesion on one side producing hemianopsia. When, 
however, there is an aneurism of the central artery or vein, or an inflamma¬ 
tion of the optic nerve, the fibres in close proximity supplying the macula 
are implicated, and central blindness or a scotoma results. This is seen 
in tobacco- and alcohol- amblyopia. 

THE FIELD OF VISION. 

A lesion which obstructs the visual pathway beyond the chiasma or 
destroys the visual centres in the cuneus causes lateral homonymous hemia¬ 
nopsia. 

Hemianopsia or Hemianopia (Half-blindness).—If the blind half be 
toward the same side in both eyes, it is called homonymous; if on opposite 
sides, it is known as heteronymous hemianopsia. It may be complete or 
incomplete, according to the involvement being of one-half the field or 
merely a sector of it. It may be absolute or relative, as the blind field is 
totally or partially blind. The hemianoptie field usually shows an inden¬ 
ture at the point of fixation corresponding to the overlapping of the nerve- 
supply to the macula. 

The right optic tract contains all the nerve-fibres going to the right 
halves of both eyes. Its division would cause half-blindness on the opposite 
side of the field of vision. Those on the nasal side decussate to the right 
half of the left eye. Those on the temporal side continue forward on tl\e 
same side (see Fig. 416). 

Longitudinal division of the chiasma would cut off all the fibres to the 
nasal halves of the retina?, and produce double hemianopsia —blindness 
to the right for the right eye and to the left for the left eve. Pressure 
on the third ventricle or enlargement of the pituitary gland may be the 
cause. A lesion of the chiasma laterally would cause blindness on the tem¬ 
poral side of the retina. In rare instances bilateral blindness in the nasal 
fields has been produced by corresponding lesions on each side affecting the 
non-decussating fibres. A double temporal or nasal blindness can occur 
only in diseases of the chiasma. The chiasma may be the seat of tumors 
or syphilitic growths or may be pressed upon through the third ventricle 


THE OCULAR MANIFESTATIONS OF NERVOUS DISEASES. 


737 


in hydrocephalus. Gouty changes and interstitial hemorrhage have been 
observed. Migraine and hysteria may cause temporary hemianopsia. 
Superior and inferior , or altitudinal , hemianopsia is very rare. The optic 
tract may be involved by traumatism, hemorrhage, softening, basilar tumors, 
or thickening in multiple sclerosis. One eye may be entirely blind from de¬ 
generation of or from injury to the optic nerve, or from tumor, aneurism, 
basilar fracture, or caries of the sphenoid bone. 



Fig. 416.—Diagram of right homonymous hemianopsia and of the sites 
of lesions which may cause it. 


RE, Right eye. LE, Left eye. ON, Optic nerves. C, Cbiasma. OT, Optic tracts. 

Th, Thalarui optici. G, Corpora geniculata. Q, Corpora quadrigemina. RC, Right 
cuneus. OR, Optic radiations. 

FOCAL LESIONS OF THE BRAIN. 

Brain diseases are the most frequent causes of both optic neuritis and 
optic-nerve atrophy. The disease may be focal or diffuse. Focal lesions 
producing optic neuritis are usually caused by tumors, but foci of softening, 
abscesses, thrombosis of the sinuses, aneurisms, apoplexies, and c\ sts may be 
the pathologic factors. Optic neuritis may be the first and only evidence of 
the disease. Even the vision may not fail until post-neuritic atrophy sets 


47 






















738 


MODERN OPHTHALMOLOGY. 


in. Becurrent transient loss of vision may be a prominent symptom of 
brain disease whether focal or dilfuse. Similarly situated focal lesions may 
give rise to very different symptoms. There may be merely an irritation of 
the centre causing increased functional activity, or a 'paralysis of the centre 
may destroy the function of the part. If between the two, there is a paresis 
of the centre, with only a partial loss of function. 

The most prominent symptom of focal disease may be the disturbance 
in the field of vision, usually hemianopsia. If the lesion exists anywhere 



Fig. 417.—Diagram of Wernicke’s pupil symptom. 

P, The pupil. T, Centre for vision. ON, Optic nerve, OT, Optic tract. M, Meynert’s 
fibres from Z (the geniculate body) to N (the nucleus of the third nerve). Thence by the 
third nerve to CG (the ciliary ganglion) and by the short ciliary nerve (ON) to the sphincter 
pupillse (P). A lesion beyond Z would not disturb the pupillary reflex. Sn, Third nerve. 

between the cortical centre and the chiasma,—for example, in the right optic 
tract,—the nerve-fibres going to the right half of each retina will be cut 
off, and the left fields of vision will be cut out —left homonymous hemia¬ 
nopsia. If the lesion is in the chiasma, the decussating fibres to the nasal 
side of the retina will be involved, and the opposite fields may be blind— 
bitemporal hemianopsia. If the lateral fasciculi of both sides of the chiasma 
should be coincidently involved, the temporal halves of the retinae would be 
cut off and binasal hemianopsia would result. 

















THE OCULAR MANIFESTATIONS OF NERVOUS DISEASES. 


739 


By means of the liemianoptic pupil-symptom of Wernicke a differential 
diagnosis between lesions of the tract and the cortical centre may be made. 
If the pupil responds to light thrown on the amaurotic retina, the lesion 
is back of the geniculate bodies. The presence of this reaction indicates that 
the pupillary nerves which accompany the optic tract as far as the geniculate 
bodies are not involved. There the afferent pupillary nerve leaves the tract 
by way of Meynert’s fibres to become the efferent impulse to the pupil, going 
first to the gray matter of the aqueduct of Sylvius, then to the third-nerve 
nucleus, and from there through the short root of the ciliary ganglion to the 
ciliary ganglion and the short ciliary nerves to the sphincter pupillae. If 
the lesion is in. the path of the pupillary reflex, the pupil would fail to 
react (see Fig. 417). 

Visual Amnesia, or Mind-blindness, is another symptom which may be 
present in focal brain trouble. The patient perceives an object perfectly, 
but has no memory of what it is. By closing the eyes it may be recognized 
by touch or by the other senses. This symptom is present when the lesion 
is in the centre for visual memory or in the path connecting the centre for 
vision with the centre for visual memory. In these higher visual centres 
both eyes are represented in each hemisphere. They are situated in the an¬ 
gular gyri of the parietal lobes, and communicate with each other through 
the callosal crossway. A lesion in this region does not cause hemianopsia. 

Alexia, or Word-blindness, consists in the inability to read written or 
printed words, although the same words may be used fluently in conversa¬ 
tion. Individual letters can be usually recognized (subcortical alexia). It 
may be combined with an inability to write (agraphia, cortical alexia). 
According to Dejerine and Wernicke, word-blindness with agraphia is due 
to a lesion in the left angular gyrus and inferior parietal lobule—the centres 
for visual word-memories. 

Visual Aphasia consists in inability to name an object which the pa¬ 
tient sees and of which he knows the use. He always gives the object a 
wrong name. If the eyes are closed, the other senses will recognize the ob¬ 
ject. Freund places the lesion in the left occipital lobe in the path from 
the centre of visual memory in each hemisphere to the speech-centre in the 
left hemisphere. 

Dyslexia is a disgust for reading after a few words or lines are gone 
over. It may precede grave brain trouble. The seven or eight cases on 
record were all fatal. According to the autopsies, the lesion is around 
Broca’s lobe. 

Amnesic Color-blindness.—The patient cannot name the color of an 
object, although he distinguishes color and can perform color-tests per¬ 
fectly. 

Visual Hallucinations may occur in the blind fields in cases of hemia¬ 
nopsia which should not be mistaken for the visual hallucinations of 
insanity. They are supposed to be due to an irritation of the visual mem¬ 
ory-centre. 



740 


MODERN OPHTHALMOLOGY. 


OCULAR SYMPTOMS OF ORGANIC DISEASES OF THE BRAIN 

AND SPINAL CORD. 

Meningitis.— 1 . Pachymeningitis, or Inflammation of the Dura, 
may cause optic neuritis. When the inflammation and pressure are at the 
base of the brain, the fields of vision may be affected from pressure on the 
optic tracts or nerves; and pressure on the third and sixth nerves may cause 
ocular palsies. Involvement of the fifth nerve may cause pain or insensi¬ 
bility in the regions which it supplies. Inflammation of the dura is less 
severe than is that of the pia mater. 

2. Leptomeningitis (Acute Cerebral Meningitis; Cerebrospinal 
Meningitis). —There are early external inflammatory symptoms, such as 
conjunctivitis and swelling of the lids. The cornea may be infiltrated. 
The pupils at first are usually contracted, and later dilated, or they may be 
immovable. After a few days the optic disc may become hazy and the ves¬ 
sels are enlarged. The papillitis may be severe, the disc becoming obscured 
and subsequently atrophied. Blindness may ensue. Retinal hemorrhages 
and neuroretinitis are not infrequent. The severe infection may cause 
purulent iridochorioiditis and panophthalmitis. The third nerve is usually 
affected, and strabismus, or a loss of conjugate action, results. 

3. Tubercular Meningitis. —Miliary tubercles are often present in 
the chorioid, but Cohnheim has pointed out that they are not as frequently 
observed as in general tuberculosis without meningitis. The base of the 
brain is usually involved in tubercular meningitis, in consequence of which 
optic neuritis and the orbital paralyses are more frequent than in other 
forms of meningitis. 

Multiple Sclerosis (Disseminated Sclerosis) is rich in eye symptoms, 
upon which much depends for its early diagnosis. Any portion of the eye 
may be affected. The pupils are likely to be contracted, and unequal in 
size, with diminished reaction to light and accommodation, but the Argyll 
Robertson pupil is very rare. According to Uhthoff, the extrinsic eye- 
muscles are involved in 17 per cent, of the cases. The disturbance is usually 
bilateral and transient. One muscle only may be paralyzed or there may be 
complete ophthalmoplegia. The nuclear nature of the disease is sometimes 
shown in the lack of associated movements. Nystagmus is a very frequent 
symptom, true nystagmus being present in 20 per cent, of the cases, and the 
remainder usually show nystagmiform movements—the ocular ataxia of 
Swanzy. These are shown by directing the patient to look from the 
usual line of sight: e.g., up and out. 

Optic-nerve atrophy occurs in about 50 per cent, of the cases. The 
process is generally a slow one, and is seldom extreme. Vision may be 
more or less affected. A transient form of blindness is not uncommon. 
Hemianopsia is never present, which, as a localizing symptom, places the 
lesion, as far as visual symptoms are concerned, peripheral to the optic com¬ 
missure, although the lesions causing the different ocular palsies may be as 


THE OCULAR MANIFESTATIONS OF NERVOUS DISEASES. 


741 


far back as the nuclei of the nerve governing the muscle. The occa¬ 
sional disturbances in the field of vision are central scotoma, irregular 
and regular retraction of the field, and discliromatopsia, particularly for red 
and green. 

Locomotor Ataxia (Tabes Dorsalis).—Probably no other nervous dis¬ 
ease has so many characteristic eye-symptoms, many of which are present 
long before the ataxic symptoms show themselves, and, indeed, the diagno¬ 
sis is often made from the early ocular symptoms. 

There is apt to be a contraction of the pupil, in some cases almost to a 
pin-point size (spinal miosis), although the pupil may react promptly to 
light and convergence. This condition is to be considered as either a paresis 
of the pupil-dilating fibres from disease in the front part of the aqueduct 
of Sylvius or as a paresis due to disease of the cilio-retinal centre in the 
lower part of the cervical cord. The pupils may be normal, or they may 
be accidentally dilated as a result of a general third-nerve paralysis. The 
Argyll Robertson pupil is found most frequently in this disease. In this 
the irides do not reach to light, or, if they do, it is but very sluggishly, but 
they react promptly in convergence. This symptom may be present when 
there is miosis, when the pupils are normal, or—as more generally occurs— 
when there is some inequality of the pupils (anisocoria). This is an early 
symptom of tabes, and it may make the diagnosis reasonably certain long 
before the development of any ataxic gait. 

Paresis of one or more of the ocular muscles with its accompanying 
diplopia occurs in 30 per cent, of the cases of tabes. These may be transient 
or permanent in nature. The sixth nerve seems to be the one most often 
attacked, but the third is not infrequently affected, together with its branch 
to the levator palpebrse, causing a true ptosis. Paralysis of accommodation 
occurs rarely in this disease, and is nearly always a late symptom. 

There is often a narrowing of the palpebral fissure and a slight droop¬ 
ing of the upper lids, but, as the patient can by his will-power open them 
normally, it is not to be considered as a true ptosis. On closing one 01 ; 
both eyes there is often a marked twitching of one or both orbiculares. This 
symptom is not of much importance, as it is not infrequently present in 
persons who are perfectly well. 

Epiphora is a symptom mentioned by some authorities, and is due 
probably both to a relaxation of the lower lid and to hypersecretion of the 
lacrimal gland. Berger claims to have frequently found a reduction of 
intra-ocular tension, but this contention is not borne out by other observers. 

Some authorities mention nystagmus as a symptom of tabes, but prob¬ 
ably Swanzy’s term, ocular ataxia, is better. This consists in a nystagmus 
developing when the patient attempts to fix an object with his eyes, but 
which ceases the moment the eyes are at rest. 

A symptom which occurs in at least 30 per cent, of cases is optic-nerve 
atrophy. It is an early rather than a late symptom, and cases are on record 
where it has preceded the ataxic gait twenty years. The atrophy is nearly 


742 


MODERN OPHTHALMOLOGY. 


always bilateral, although generally more advanced in one eye than in the 
other. As the atrophy advances there is a concentric contraction of the 
visual field, especially so to the outer side. Central vision may remain good 
for a long time. Sometimes the field shows only a sector-like defect. As a 
result of the atrophy, color-blindness is not infrequent, the recognition of 
green being lost generally before that of red. The inequality of the pupils 
is probably explained by the atrophy of one optic nerve being much more 
advanced than that of its fellow. 

Pseudobulbar Paralysis of Cerebral Origin. —This affection usually has 
no eye-symptoms. If they are found, they serve to establish a differential 
diagnosis from true bulbar paralysis, which has no eye-symptoms. When 
ocular symptoms are present they may consist of any one or more of the 
following: Optic neuritis, optic-nerve atrophy, and impossible or difficult 
voluntary closure of the eyelids, while reflex closure is normal. Other vol¬ 
untary movements of the eyeball may be impossible, although all involuntary 
movements take place. 

Combined Sclerosis of the Spinal Cord (Ataxia Paraplegia of Gowers; 
Postero-lateral Sclerosis). —Inequality of the pupils, irregularity of outline, 
and sluggishness in the mobility of the iris are frequently seen in this affec¬ 
tion. The light-reflex is rarely lost. 

Friedreich's Ataxia (Family Ataxia). —Hereditary ataxia bears con¬ 
siderable resemblance to locomotor ataxia, but its ocular manifestations are 
exceedingly limited as compared to the latter affection. Nystagmus and 
nystagmiform movements, increased by effort, are the most marked ocular 
symptoms. In Friedreich’s form, optic-nerve atrophy is very rare. In 
Marie’s form, the hereditary cerebellar ataxia, it is a common symptom, as 
is also a loss of pupillary reflex, which is not found in Friedreich’s type. In 
Marie’s type, changes in the form- and color- fields have been noted, 
together with a loss of visual acuity. 

Acute Ascending Paralysis. —This is rarely accompanied by ocular 
.symptoms, but there may be ocular palsies, paralysis of accommodation, and 
mydriasis. 

Myelitis. —When optic neuritis is associated with myelitis of the cord, 
it is due to a similar process in the optic nerve. If the disease is in the lower 
cervical or the upper dorsal region, the cilio-retinal centre may be irritated 
and mydriasis results, or it may be paralyzed and cause miosis. 

Multiple Neuritis. —Toxic agents—such as alcohol, lead, arsenic, and 
carbon gases—which may cause multiple neuritis may also produce a toxic 
amblyopia. The vision may be reduced. The pupils have been observed to 
be dilated, contracted, or irregular. The accommodation is usually dis¬ 
turbed in diphtheritic neuritis. In the latter disease diplopia occurs in 10 
per cent, of cases, and less frequently in alcoholic neuritis. The motor 
nerves of the eye may be singly involved, as in ptosis, but there may be 
complete ophthalmoplegia, which is usually nuclear in origin. Optic neu¬ 
ritis, contracted fields, and color-scotoma may complete the eye-picture. 


THE OCULAR MANIFESTATIONS OF NERVOUS DISEASES. 


rv \ o 
( “rO 

Migraine may cause portions of the eyebrow or the cilia of the lids to 
turn gray. The attacks may be preceded by scintillating scotomata or 
visual hallucinations. Optic-nerve atrophy sometimes sets in where the 
disease has been persistent for some time. It is likely to be mistaken for 
glaucoma. Forms of oculomotor paresis are not infrequent, and a special 
classification of “ophthalmoplegia migraine” has been suggested. 

Neuralgia.—This occasionally gives rise to canites. Optic-nerve 
atrophy is sometimes found, and these cases should be suspected of glau¬ 
coma. Temporary amaurosis is not infrequent. Neuropathic keratitis with 
ulceration of the cornea may be due to interference with the trophic centre 
of the fifth nerve. 

Herpes Zoster.—This occurs in the distribution of the fifth nerve, 
especially the ophthalmic branch. Blebs may form on the cornea and the 
sight may be more or less reduced. They heal with a disfiguring opacity. 

General Paralysis of the Insane.—General paresis is rarely accom¬ 
panied by optic-nerve atrophy. It is apt to occur early in the disease. The 
most important pupillary sign is the absence of light-reflex. Miosis may 
be extreme in the early stage, followed in the late stage by mydriasis. There 
is variable inequality of the pupils. Simple constant inequality is met 
with in ordinary insanity. 

The paradoxic pupil, in which the pupil first contracts to a beam of 
light, then partly dilates, and then oscillates, and finally remains dilated 
widely regardless of the light, is a forerunner of paresis. There may be a 
loss of consensual pupillary reflex. The third and sixth nerves are some¬ 
times involved early. Ptosis, transient nystagmus, and twitching of the 
lids may occur. Mind-blindness may come on in the late stages. The field 
of vision is not impaired. 

Insanity.—Fundal and other ocular disturbances are so rare as to be 
considered coincident. Visual hallucinations may annoy the patient. 

Paralysis Agitans.—A fine fibrillary tremor takes place along the mar¬ 
gin of the upper lid, especially marked when the eye is closed. 

Infantile Paralysis.—Usually no eye-symptoms are presented, but optic 
neuritis, hemianopsia, and paralysis of the ocular muscles have been noted. 

Tetany.—A form of nuclear cataract which progresses very slowly is 
sometimes found. 

Hydrocephalus.—The ocular symptoms of this disease are those which 
result from pressure on the optic chiasma by the distended third ventricle, 
namely: bitemporal hemianopsia, optic neuritis, and optic-nerve atrophy, 
the latter being secondary or primary according to the severity of the attack. 
Strabismus is not uncommon. 

Acromegalia.—The eyebrows are coarse and heavy. Thickening of the 
bony walls of the orbit may cause exophthalmos and intra-ocular pains. 
Pressure from a tumor of the pituitary gland may cause double optic neu¬ 
ritis and optic-nerve atrophy. Ocular palsies and nystagmus may be 
present. 


744 


MODERN OPHTHALMOLOGY. 


Thomsen’s Disease (Myotonia Congenita).—This rare disease is char¬ 
acterized by a rigidity of the voluntary muscles. It is seen in different 
generations of neurotic families, and is either a disease of the muscles 
themselves or a trophoneurosis. There is at times a disorder of the mus¬ 
cular apparatus of the eyes. The lids may partake of the general muscular 
stiffness. Amblyopia of a temporary character has been observed. 

Syringomyelia and Morvan’s Disease are characterized by sensory and 
trophic disturbances, and cause, in some cases, concentric contraction of 
the field of vision without any fundus changes discernible. 

Epilepsy has no characteristic eye-symptoms, although few, if any, 
attacks of epileptic convulsions are unaccompanied by more or less of them. 
The most frequent is visual aura —a subjective symptom elicited from the 
patient. He may describe it as a sensation of light, color, flames, or flushes. 
Visual aura is strongly indicative of organic trouble in the occipital lobe, 
especially if homonymous. Conjugate lateral deviation of the eyes to the 
opposite side of the body from that in which the convulsive movements 
began may occur at the beginning of an attack. The head inclines in the 
same direction. Later the eyes turn strongly in the opposite direction. 

The action of the pupils during an attack is varied. They may be 
strongly contracted or widely dilated, or they may be both during the same 
attack. A rapidly changing pupil after an attack of unrecognized nature 
is diagnostic of epilepsy. The ophthalmoscopic appearance of the fundus 
during a convulsion may be normal, or there may be extreme pallor of the 
disc with contraction of the vessels, or hyperemia of the disc with dilation 
of the vessels. Following the convulsion there is often a transient con¬ 
centric narrowing of the field of vision and lowered acuity of vision. 

Subconjunctival ecchymosis and opacity of the lens or complete cataract 
following an epileptic seizure are to be regarded as accidents rather than 
symptoms of the disease. 

We have been considering epilepsy and its ocular symptoms as of 
organic origin, but it should also be considered as a reflex phenomenon, due 
to an irritation, the seat of which may be in the eye itself. An error of 
refraction, especially one of high degree, or much astigmatism is sometimes 
the cause, and its correction may prevent or ameliorate the attacks. In 
the same manner the correction of muscular insufficiencies by advancements 
and tenotomies has effected cures, but the results have not been as brilliant 
as could be reasonably expected. 

Chorea.—Blepharospasm is sometimes a forerunner of a general attack 
of chorea. As in epilepsy, errors of refraction seem at times to be the cause 
of chorea, and wearing the proper correction may cure the disease. In the 
few cases reported of embolism of the cerebral artery accompanying chorea 
the coexistence of endocarditis with which chorea seems to be so intimately 
connected has been assigned as the cause of the emholi. Chorea not infre¬ 
quently shows a low-grade neuroretinitis, and even a decided papillitis mani¬ 
fests itself at times. 


THE OCULAR MANIFESTATIONS OF NERVOUS DISEASES. 


745 


Exophthalmic Goitre (Graves’s Disease; Basedow’s Disease). —Various 
theories have been advanced as to the cause of exophthalmic goitre. They 
point to a nervous origin to account for the three pronounced symptoms, 
namely: exophthalmos, enlargement of the thyroid, and tachycardia. The 
last is the most constant. Either of the others may be wanting. Until 
recently a lesion of the cervical sympathetic was supposed to cause a paraly¬ 
sis of the vasomotor nerves producing vascular dilation of the carotids and 
the vessels supplying the thyroid and the orbits, the tachycardia resulting 
from irritation of the excitomotor nerves of the heart. Division of the sym¬ 
pathetic experimentally in animals has failed to produce these results. 
Filehne divided the restiform bodies and produced an exophthalmos, but no 
tumefaction of the thyroid. He believes, in accordance with Sattler’s 
theory, that there is a lesion of an area of the brain the nerve-fibres of which 
pass through the restiform body, the vagus being involved to account for the 
tachycardia, the exophthalmos and goitre being caused by the absence of the 
vasomotor supply-—and the consequent vascular dilation. 

The eye-symptoms may first direct attention to the disease. The ex¬ 
ophthalmos, or proptosis , may be the most prominent. It may be noticed 
that when the eyeball is directed downward the upper lid does not follow it 
steadily, but in a jerky manner (von Graefe’s sign). The upper lid is more 
or less retracted (Dairyniple’s sign). These two symptoms may be wanting. 
Owing to the proptosis, the lids do not come together during the act of 
winking, and this gives rise to Stellwag’s sign, which is an imperfect and 
abnormal infrequency of nictitation. There may be a minute’s tune be¬ 
tween the involuntary winking movements. The increased exposure of the 
cornea may permit it to become covered with pannus. During sleep the 
cornea may remain uncovered, and sloughing may follow from inability to 
close the lids. Diplopia develops at times from the restricted movements 
caused by the proptosis, with or without a paresis of the muscles. 

As a rule, Graves’s disease shows very slight changes in the fundus. 
The arteries are usually larger than normal and about the same size as the 
veins. At times there is a strong arterial pulsation. 

ASTHENOPIA, AMBLYOPIA, AND AMAUROSIS OF NERVOUS ORIGIN. 

The sight may become weak, partially and even totally lost, without any 
organic cause, but merely from functional nervous derangement. Neuras¬ 
thenia, hysteria, and neuroses following injury may give rise to such symp¬ 
toms. The hysteric element which underlies these conditions occasions 
contradictory and confusing reports, and care must be exercised lest such a 
patient be considered a malingerer. The sight of an hysteric amblyopic eye 
may be improved by a plane glass, which by psychic effect would remove the 
inhibition to sight. The ophthalmoscope may show a perfectly normal eye- 
ground, and no error of refraction may be present. 

Neurasthenia. —By exhaustion of the accommodation and insufficiency 
of the interni muscles the neurasthenic patient, especially when a school- 


746 


MODERN OPHTHALMOLOGY. 


child, will complain of blurred vision, lamination, and headache. Photo¬ 
phobia, visual hallucinations, and photopsia (bright-colored or glittering 
spots before the eyes) are sometimes experienced. Depression or excitation 
of spirits, irritability of temper, insomnia, and vertigo are sometimes accom¬ 
paniments of this condition. In adults the subjective symptoms of neuras¬ 
thenia are periorbital, supra-orbital, or vertex pains; shooting and boring 
pains in the eyeballs; and pain on eye-movements. Sensations of heat or 
cold and dryness of the lids may be noticed. When glasses are worn, the 
patient may complain of the reflections of light from the edges of the glass 
or from the frames. The patient may persistently see the tip of the nose. 

In nervous asthenopia and hysteria the very effort to see diminishes the 
acuity of vision and lessens the extent of the field of vision. This is shown 
in the so-called fatigue-field. If the small five-millimetre-square test-object 
on the perimeter be repeatedly used in the same meridian, and recorded each 
time (Wilbrand’s method) it will be noticed that the field becomes more 
contracted, perhaps as far as ten or five degrees of the fixation-point. Fleet¬ 
ing, island-like defects in the field of vision are characteristic of nervous 
amblyopia. The functional derangements of vision may temporarily exag¬ 
gerate the constant defects of sight and of the field of vision which are due 
to organic disease. 

Hysteria.— In hysteric amblyopia the patient may complain of a com¬ 
plete amaurosis of one or both eyes, but usually of but one. Generally 
amblyopia only is observed, and rarely does complete blindness occur. It is 
accompanied by a concentric contraction of the field of vision, and a trans¬ 
position or overlapping of the color-fields, or in some cases complete color¬ 
blindness. There may be spasms of the accommodation, blepharospasm, 
and a paralysis of the orbital muscles. Orientation may be difficult. 

Monocular diplopia and polyopia not infrequently complicate hysteric 
amblyopia. They are, however, rarely complained of by the patient, and 
are elicited only after a careful test. The phenomena are really due to . 
different images being thrown on the retina when the eye is unable to focus 
while there is a spasm of the accommodation. Each sector of the lens pos¬ 
sesses a focal point of its own capable of throwing a distinct and separate 
image of the same object on the retina. 

In all cases of hysteric amaurosis the pupil reacts normally to light. 
This serves to differentiate it from other forms of blindness. When monocu¬ 
lar amaurosis is a symptom, it is often possible to prove binocular vision 
by the prism test, two objects being seen when a prism is placed before one 
eye. A person thus tested is not necessarily a malingerer. A malingerer 
would not present changes in the form- or color- fields or show the fatigue- 
field. In hysteria there are no ophthalmoscopic changes in the eyeground. 
There may be an insufficiency of accommodation and a weakness of con¬ 
vergence, when the eye is emmetropic and the ocular muscles are fully 
developed. The eye-muscles may be paralyzed, or they may be excessively 
contracted. 


THE OCULAR MANIFESTATIONS OF NERVOUS DISEASES. 


747 

Neurosis following Traumatism. —The most marked symptom is con- 
centiic contraction of the field of vision, but it is not always present or 
pronounced. The color-fields show greater variation than the form-fields, 
hut their relative boundaries are not often changed. Both eyes are usually 
affected. Hemianesthesia when present is usually on the side of the more 
contracted field. The fatigue-field may be present. 

The pupil-reflex is usually normal, but may be wanting. There may 
be a difference in the size of the pupils. Insufficiency of the internal recti 
muscles is not rare. Blepharospasm, photophobia, and sensations of light 
and color may be present. 

Treatment. —General and nerve-tonic treatment is indicated for all 
functional nervous disorders. Eye work should be stopped and tinted 
glasses prescribed. A change of air and scene, exercise without fatigue, 
bathing, and proper diet should be advised. 

OTHER FORMS OF AMBLYOPIA AND AMAUROSIS. 

Besides hysteric amblyopia, which has been considered, there are other 
forms, viz.:— 

1. Amblyopia Caused by a Distukbance of the Cerebral Circu¬ 
lation.— It niay be accompanied by scintillating scotomata and concentric 
defects in the fields of vision. Homonymous hemianopsia and migraine 
are characteristic concomitant symptoms. 

2. Reflex Amblyopia. —Irritation of the fifth nerve due to carious 
teeth has jiroduced defects of vision. Intestinal worms, intestinal diseases, 
disease of the naso-pharynx, and other organic diseases have caused am¬ 
blyopia. Reflex amblyopia is supposed to be a vasomotor disorder in which 
the nutrition of the retina or of the central ganglia is affected. 

3. Congenital Amblyopia.— Ocular diseases—such as diseases of the 
optic nerve, chorioidoretinitis, iritis, and glaucoma—may exist in intra¬ 
uterine life and permanently affect the sight. Colobomata and an arrest 
of development may involve the optic nerve and the other parts of the eye 
or the entire eye (microphthalmos). Ametropia of high degree may cause 
one eye to go out of use (exanopsia). 

4. Uremic, Glycosuric, Malarial, Lead, Drug, and Ptomain Am¬ 
blyopia, and other forms, non-nervous in origin, will be elsewhere con¬ 
sidered. 

5. Pretended Amblyopia and Amaurosis.— If the patient pretends 
he is blind in both eyes, the detection may be difficult. Feints at striking 
the face may cause a lid-reflex or a strong light may cause a pupil-reflex, 
but the latter reflex may be present in a blind eye if the lesion is behind 
the reflex efferent pupillary nerve-fibres. 

Test for Binocular Blindness. —A lighted candle is placed in front 
of the patient, and a 6° prism with its base out before one eye. If the 
eyes see, the one behind the prism will move inward, and outward again 
when the prism is taken away. (Priestley Smith and E. Jackson.) 


748 


MODERN OPHTHALMOLOGY. 


Tests for Non-ocular Amblyopia. — 1 . Diplopia Test. —Have the 
patient look at an object with a prism base up or clown before the good eye. 
He is apt to say he sees two objects, which is impossible if one eye is blind. 
The prism must be fully over the good eye, so that monocular diplopia is 
not produced. 

2. The Crossed Diplopia Test. —If a prism of 10° is held base outward 
before the pretended blind eye, the eye will rotate inward if it has sight. 

3. Color Test. —The patient looks at red and green test-type. A green 
glass is put before the good eye. If he sees the red letters he does so with 
the pretended blind eye. 

J+. Harlan’s Test.- —Place a —J— 14 D. lens before the good eye, and a 
— 0.25 D. lens before the pretended blind eye. The good eye is thereby 
excluded, and, if the patient can see test-type, he does so with the pretended 
blind eye. 

Erythropsia (Red Vision). —Occasionally patients with aphakia and 
others have red vision lasting perhaps but a moment or a few minutes, and 
recurring at irregular intervals. It has been noticed in optic-nerve atrophy, 
glaucoma, and santonin poisoning. The latter may also cause yellow vision 
(xanthopsia). The cause of such visual disturbances is not positively 
known, but it is probably an overexcitation of the visual nervous apparatus. 


CHAPTER XXIII. 


PREPARATION FOR OPHTHALMIC OPERATIONS. 

The successful practice of the operative surgery of the eye requires a 
combination of factors, all of which must harmonize if the desired result 
is to be attained. It is necessary to consider the preparation of the surgeon 
and of his assistants, tlie preparation of the patient, the advisability of em¬ 
ploying an anesthetic, the judicious selection and preparation of instruments, 
and, finally, the surroundings of the patient during and after the operation. 

Qualifications of the Surgeon.—It is assumed that the ophthalmic 
surgeon is an educated gentleman. He should not be so young as to 
destroy confidence nor so old and feeble as to jeopard, by unskillful manip¬ 
ulation, the result of an operation. He should have excellent vision. His 
hand should be steady. He should be a good judge of human nature and 
should have the art of inspiring confidence. His habits of life should be 
regular. He should not be given to excesses of any kind. He should be 
quiet, thoughtful, studious, and attentive. He should be considerate of 
the feelings of his patient and of his confreres. He should be circumspect 
in his opinions, respectful to his superiors, just to his colleagues, and 
honorable in his dealings with them and with the public. He should be 
not too eager to adopt new methods of doubtful utility or too slow to profit 
by new ideas and discoveries. He should willingly give his time and 
talents to the poor. From time to time he should publish the results of 
his observation and experience, in order that other members of the pro¬ 
fession may profit thereby. He should frequently visit the clinics of the 
great masters of ophthalmology to keep pace with the rapid advances 
which are being made in the science and art of ophthalmic surgery. His 
assistants shovdd be selected with care and with a view solely to their 
qualifications. 

Advanced age is not a disqualification for a surgeon, provided his 
hand be steady and his vision good. Owing to narrowing of the pupil, the 
aged surgeon will require more light than his younger confrere. Presbyopia 
of high amount will limit the surgeon’s usefulness, since he can see clearly 
at only a fixed distance. The disadvantages of age are often more than 
balanced by the teachings of experience. 

If not ambidextrous, the surgeon should become so by practicing upon 
the eyes of dead persons or on those of animals. For the purpose of 
acquiring proficiency in this line the enucleated eyes may be fastened in 
an operating mask (ophthalmophantome), which permits of an extensive 

(749) 


750 


MODERN OPHTHALMOLOGY. 


range of movement. The ambidextrous surgeon possesses a marked ad¬ 
vantage over his confrere who is not thus equipped, and this advantage is 
particularly noticeable in such delicate procedures as iridectomy and 
cataract extraction. 

Preparation of the Surgeon and Assistants.—Cleanliness is a necessity 
in ophthalmic surgery. This means that the operator, his assistants, his 
instruments, and his patient should be aseptic or in a state as nearly ap¬ 
proaching thereto as is possible. The surgeon’s clothes, his nose and mouth, 
and his beard (if one is worn) should be clean. Special attention should be 
given to the preparation of the hands. The following routine is recom¬ 
mended :— 

1. Washing with ordinary soap and hot water. 

2. The finger-nails should be cleaned. 

3. Weir’s method of hand-disinfection should be employed. 

After washing as above, a tablespoonful of small crystals of sodium car¬ 
bonate is placed in the palm of one hand, to which one-third as much 
chlorid of lime is added. After moistening with water, the mixture is to 
be rubbed into the skin. This should be followed by a rubbing with a 
sterile towel and by rinsing in sterile water, in bichlorid solution (1 to 
3000), or by washing in a solution of permanganate of potassium followed 
by an oxalic-acid solution for decoloration. The sodium-carbonate lime- 
chlorid method releases chlorin-gas and reaches recesses of the skin which 
by other methods of preparation may not be cleared of pathogenic bacteria. 

4. After preparing his hands the surgeon should not touch unsterile 
substances until after the operation has been finished. 

Preliminary Preparation of the Patient.—Operations are divisible into 
those of election and those of necessity. In the former time is given in 
which to examine the general state of the patient, and to institute such 
treatment as is necessary to place him in the most favorable condition for 
operative measures. In the latter class of cases the surgeon has no time in 
which to institute general treatment. He must be content with determining 
the state of the heart and great vessels and of the lungs, if a general anes¬ 
thetic is required. 

Wherever it is possible to do so, eye operations should he placed in the 
class of operations of election. Nearly all cases of cataract, of strabismus, 
and of lid diseases will naturally fall under this division, while many cases 
of injury and of glaucoma will require immediate intervention. 

Rheumatism, gout, diabetes, albuminuria, arteriosclerosis, bronchitis, 
cold in the head, alcoholism, epilepsy, and cardiac and hepatic affections 
should be treated systemically and systematically for some time before opera¬ 
tion. If the patient is of advanced age and is decrepit, the administration 
of tonics and stimulants will be required. 

While age in itself is not a barrier to a successful operation, the prog¬ 
nosis in decrepit individuals is less favorable than in those who are stronger. 
Old people should not be permitted to lie on their backs for long periods. 


PREPARATION FOR OPHTHALMIC OPERATIONS. 


751 


since hypostatic pneumonia may develop. Any general or local septic condi¬ 
tion which may be present should receive attention. The same is true of 
skin diseases, particularly those which cause itching. 

Search should be made for hemophilia. If the patient is a “bleeder” 
or comes from a family of bleeders, the fact will not only ha\e a bearing 
upon the prognosis, but will influence the choice of operative procedures. 
The hemophile should be given a course of preparatory treatment. 

Attention to the condition of the throat and nasal chambers of the 
patient is of importance. If pharyngitis, tonsillar enlargement, or rhinitis 
be present, either in acute or in chronic forms, it will be advisable to insti¬ 
tute a course of local treatment before proceeding to operate upon the eye 
or its adnexa. The state of the lacrimal passages is of great importance in 
any case which requires opening of the eyeball. If dacryocystitis is present 
it should be thoroughly treated long before the execution of any operation 
upon the globe. 

The evening before the operation the patient should take a bath, and, 
if a male, should be shaved. The epilation of the cilia a few days before the 
operation has been advocated by Schioetz and Hjort. This practice has not 
met with favor. Some surgeons, for the purpose of determining whether 
the conjunctiva is inflamed, apply a test bandage the evening before opera¬ 
tion. This procedure is valueless, unless, as in the method of Schmid t- 
Rimpler, care is taken to inoculate the cornea of a rabbit with the accumu¬ 
lated secretion. ' 

Time for Operation.—Eye operations are performed successfully m all 
seasons. It will be best, however, to avoid the excessively hot or extremely 
cold periods. The spring and fall are the seasons which find favor with 
the majority of ophthalmic surgeons. Operations can be made at any hour 
of the day or night, provided skilled assistants and proper illumination can 
be secured. Many ophthalmologists operate in the morning. Perhaps an 
equal number will prefer the afternoon. It has long been the author’s habit 
to operate in the latter part of the day, both for personal comfort and for 
the reason that the patient will then have but a few hours of discomfort 
sleep soon occurring. This is particularly advantageous m the case of 
cataract patients, who, if operated early in the day, are likely to rest badly 


the first night. 

Preparation of the Region of Operation.— Although the sterilization 
of even limited areas of the conjunctiva is impossible, the necessity for 
careful preparation of the field of operation is not the less important. 
The manner of preparing the visual apparatus for an operation wi vary 
according to whether the globe and its adnexa are normal or are m a state 

oi 11 ^™” a L t ““ AND Adnexa ake Normal.— A few hours before the opera¬ 
tion the skin of the forehead, cheeks, and eyelids is to be washed with soap 
and warm water; then with alcohol or ether, to remove fatty substances, 
then with water, and finally with bichlorid solution (1 to 3000). The con- 


752 


MODERN OPHTHALMOLOGY. 


junctiva is to be flushed with sterile water or with a sterile physiologic salt 
solution. Particular attention is given to the skin of the lid-margin, about 
the roots of the cilia. Some of the French surgeons are in the habit of ap¬ 
plying an oily solution of the biniodid of mercury (1 to 2000) to the ciliary 
margin. It is advisable to remove the secretions of the sebaceous and Mei¬ 
bomian glands by compressing the margin of the lid between the thumb and 
fingers. 

The Globe and its Adnexa aee Inflamed. —Careful search should 
be made for inflammation of the lid-margins, of the conjunctiva, of the 
lacrimal passages, arid of the nasal fossas. If time permits, any disorder of 
these parts should be treated before proceeding with the operation. A sim¬ 
ple epiphora is not a bar to intervention, but it is necessary that a lacrimal 
probe be passed into the sac and upper part of the duct and that the pas¬ 
sages be irrigated with bichlorid solution. Acute diseases of the adnexa 
are rapidly improved by appropriate measures; others, on the contrary, 
require a long course of treatment. In case of absolute urgency a dacryo¬ 
cystitis may be treated by the excision of the sac, or the canaliculi may be 
obliterated by means of the galvanocautery. If the operation admits of post¬ 
ponement, it will be wise to treat the inflamed tissues for several days or 
weeks. 

Assistants.—For most ophthalmic operations only one assistant will be 
required. His duties will consist chiefly in anesthetizing the eye, in mop¬ 
ping up blood or secretions, and in passing the instruments to the surgeon. 
In complicated procedures, such aS resection of the outer wall of the orbit, 
the removal of tumors which involve the adjacent parts, excision of the 
sympathetic nerve, and extensive plastic operations, several assistants will 
be required. One will be needed to give the general anesthetic, another 
to handle gauze mops which are used to remove the blood, and a third to 
pass the instruments to the surgeon. In such procedures as the extraction 
of cataract or the performance of iridectomy one trained assistant will 
suffice. The anesthetist should be selected with care, and should attend 
strictly to the giving of the anesthetic and to nothing else. He should be 
familiar with the treatment of the accidents which sometimes occur from 
the administration of chloroform or ether. 

Preparation of the Instruments.—All large instruments should be 
washed with soap and water and brushed before and after using. Fine in¬ 
struments, such as cataract-knives and needles and keratomes, should be 
dipped in water and dried with gauze, care being taken not to injure their 
blades. Scissors, knives, keratomes, cystitomes, and iris-forceps should be 
sharpened at short intervals. All instruments should be made of metal. 
They should be purchased of a reliable manufacturer. Cheap instruments 
should not have a place in the armamentarium of the ophthalmic surgeon. 
The author prefers the instruments made by Tiemann (New York) or 
those manufactured by Weiss (London). Cataract-knives and keratomes 
should be carefully tested upon a trial drum before they are sterilized. 


PREPARATION FOR OPHTHALMIC OPERATIONS. 


753 


Their points and edges should be perfectly sharp. It will be advisable 
for the surgeon to keep several extra knives and keratomes on hand. Many 
an eye has been imperiled because of the condition of the instruments 
used upon it. As Jackson has said, “Simplicity and good judgment in the 
planning of an operation and neatness, accuracy, and rapidity in its exe¬ 
cution are absolutely essential to ideal asepsis. No routine of chemic 
antisepsis can compensate for torn, bruised, or otherwise injured tissue in 
the lips of an operative wound. In cataract extraction it is probable that 
the highest success is missed more frequently through working with a 
knife of unsuitable shape, or through applying force to it in the wrong 
direction, than through having it imperfectly ‘sterilized/ It needs to be 
more generally taught and remembered that no routine can make bungling 
surgery aseptic.” 

Sterilization by Dry Heat. —This method, which is not applicable 
to delicate instruments, is admissible for the grosser ones. They are placed 
in an autoclave and are subjected to a temperature of 150° C. If the atmos¬ 
phere is humid, the box containing the instruments should be heated before 
it is placed in the sterilizer. If this is not done, the steam will condense on 
the instruments and will rust them. 

Sterilization by Boiling Water. —This is a simple, but an efficient 
method. The instruments are placed in water which is gradually brought to 
the boiling-point, and are kept there for five or ten minutes thereafter. Car¬ 
bonate of soda or borax (2 to 100) should be added to the water to prevent 
rusting. After removal the instruments should be wiped carefully with dry 
sterile gauze. The sterilization of cataract-knives and keratomes is best 
done immediately before beginning the operation. They should be held in 
boiling water for one minute. Cystitomes should be boiled for two minutes. 
If these instruments are boiled for long periods their cutting edges will be 
dulled. 

The author intrusts the boiling of large instruments, together with the 
gauze to be used during the operation, to an assistant. The more delicate 
instruments, and particularly those which are to be introduced within the 
eyeball, are held in boiling water furnished by a portable sterilizer, which is 
placed near to the operating table. 

Sterilization by Antiseptics. —This method is inefficient, and is to 
be rejected. Chloroform, formol, carbolic acid, and strong solutions of 
bichlorid of mercury are among the agents which have been employed. 
They all produce irritation of the conjunctiva. If grease or albuminous sub¬ 
stances remain adherent to the instruments the liquid cannot come equally 
in contact with the metallic surfaces and the sterilization is inefficient. 

Preparation of Mops and Dressings.— Gauze. In the place of sponges, 
which were formerly in vogue, ophthalmic surgeons now use small pieces of 
sterile gauze to mop up blood or secretions, d o make certain that the gauze 
is sterile it should be boiled in filtered water before each operation. 

Dressings to be applied to operated eyes should be light and should be 

4S 


754 


MODERN OPHTHALMOLOGY. 


sterile. After any operation which involves opening the eyeball a few 
layers of moist sterile gauze are to be placed over the closed lids of both 
eyes and a light bandage should be applied. The use of rubber protective, 
with or without pads of absorbent cotton, is to be eschewed, since such appli¬ 
cations cause too much heat. The author always has the commercial sterile 
gauze boiled in filtered water before it is used as a dressing. What is known 
as plain gauze— i.e., not medicated—is sufficient for the purposes of the 
ophthalmic surgeon. Gauze which is impregnated with iodoform or bi- 
chlorid of mercury possesses no advantages over the plain, sterile dressing. 
In a case requiring skin-grafting a suitable dressing will be gauze which has 
been wet with a sterile physiologic salt solution. 

While a simple dressing composed of gauze and a bandage will suffice 
for most ophthalmic cases, patients who are restless, disobedient, or irre¬ 
sponsible should have a protective mask placed over the dressing. Ring’s 
mask is a good one. It is made of papier-maclie. Andrews has designated 
a shield made of aluminum, and McCoy has invented one which consists of 
two circular frames made of wire. These are curved so as to present a con¬ 
cave surface to the eye. 

Bandages should be made of soft material,— e.g., of flannel or gauze,— 
which should be light and porous. They should be sterilized by dry heat. 
The roller bandage for an adult should be two inches wide and five or six 
yards long. A bandage for a child should be of a less width. The bandage 
may be applied to one eye, the ordinary crossed bandage (monoculus), or to 
both (binoculus). Care should he taken that it is not applied too tightly 
and that the ear is not distorted. In place of the roller bandage the surgeon 
may use the bandage of Liebreich or that of Stephenson. The former con¬ 
sists of a knitted cotton or linen band, two and one-quarter inches wide arid 
ten inches long, supplied with tapes. Stephenson’s bandage is of dumb-bell 
shape, and also is provided with tapes. 

Anesthetics are divisible into general and local. 

General Anesthetics are necessary in major procedures, such as 
enucleation of the eye, exenteration of the orbit, and extensive plastic opera¬ 
tions. They are also required in iridectomy for glaucoma. In children 
and in nervous adults they may be needed for minor as well as for major 
operations. ISTitrous-oxid gas, bromid of ethyl, ether, and chloroform are 
the agents used as general anesthetics. ISTitrous-oxid gas may be used for 
operations which can be rapidly performed, such as the dilation of a lacrimal 
stricture, the opening of an abscess of the lid, or the incision of a panophthal- 
mitic eyeball. Bromid of ethyl—which finds favor with some European 
surgeons, but has not come into extensive use in this country—possesses no 
advantages over ether or chloroform. Ether is to be preferred to chloro¬ 
form, provided the patient’s lungs and kidneys are normal. Chloroform is 
extensively used in operations upon children. 

Local Anesthetics. —Cocain, eucain, holocain, and tropacocain are 
the agents used. They are employed in three ways: (1) by instillation, 


PREPARATION FOR OPHTHALMIC OPERATIONS. 


Too 


(2) by hypodermic injection, and (3) by intracutaneous injection (filtra¬ 
tion method of Schleich). 

Cocain, the oldest and best known of the group, is employed in solu¬ 
tions which vary from 1 to 10 per cent, in strength. The solution should 
be made sterile by boiling, and a fresh solution should be prepared for each 
operation. The glass of the eye-dropper also should be boiled before it is 
used. 

The hypodermic injection of cocain is made by means of the ordinary 
hypodermic syringe. This method is of especial value in the removal of 
chalazia and small palpebral growths. It is also employed in trichiasis and 
entropion operations. Some surgeons extirpate the lacrimal sac and 
remove superficial orbital tumors under local anesthesia. In all such cases 
cocain is instilled into the conjunctival cul-de-sac as well as injected be¬ 
neath the skin. 

The intracutaneous method of anesthesia is little used by ophthalmic 
surgeons. A favorite solution for this purpose is: cocain, gr. ss; sodium 
chlorid, gr. ss; water, §ss. 

Local Hemostasis. — For the purpose of producing temporary 
ischemia of the conjunctiva and of the tissues of the anterior ocular 
segment, various preparations of the suprarenal capsule are employed. 
The dried gland may be used in aqueous solution or a preparation known 
as atrabilin may be employed. Most surgeons prefer a solution of adrenalin 
chlorid, which is used in various strengths (1-10,000 to 1-2000). Soon 
after instilling such a solution the conjunctiva will appear bloodless. The 
method is of value in numerous operative procedures, such as tenotomy, 
advancement, pterygium operations, etc. Some surgeons extend its appli¬ 
cation to cases requiring iridectomy. 

The Operation Room should be clean, of suitable size, and properly 
furnished. It should contain an adjustable table on which the patient is 
to lie during the operation. Smaller tables on which to place sterile 
instruments and dressings should be provided. There should also be hot 
and cold water. The room should be illuminated by one large window, 
which preferably should face the north. In order to secure suitable 
illumination on dark days, gas or electric lights should be provided. 


CHAPTER XXIV. 


THE HYGIENE OF THE EYES. 

By HAROLD G. GOLDBERG, M.D., of Philadelphia, 

Pathologist to and Curator at the Wills Eye Hospital; Pathologist to the Ophthalmologic 
Department of the Philadelphia Polyclinic and College 
for Graduates in Medicine. 


In the field of preventive medicine—a field that has been accorded 
so prominent a place in the therapeutics of to-day—there is no more 
important division than that pertaining to hygiene; and in no branch of 
medicine is the necessity for the observance of a rigid hygiene greater than 
in that of ophthalmology. When we consider the almost vital part played 
by the eyes in the conduct of human affairs, the urgent need for a careful 
preservation of the sight becomes at once apparent. That this last is 
influenced largely by the maintenance of a proper hygiene there can be but 
little doubt. 

The care of the eyes should begin at birth and should continue unin¬ 
terruptedly throughout life. There are certain periods, however, when 
special attention is required. These will be dealt with here in their natural 
order. 

Practically speaking, a child’s future—its education, its livelihood, the 
appreciation and enjoyment of all the beauties of creation—depends upon 
the preservation of good eyesight. In spite of all the distress and discom¬ 
forts that attend a faulty vision or a loss of sight, many children are yearly 
deprived of this faculty simply through neglect to observe the common 
laws of hygiene. Carelessness in regard to cleanliness at the time of birth, 
reckless exposure of the infant’s eyes to light, pernicious school influ¬ 
ences—all these and many other violations of the laws of hygiene in regard 
to the eyes are largely responsible for the many eye diseases now in our 
midst. These laws will now be briefly discussed. 

THE CARE OF THE EYES AT BIRTH, DURING INFANCY, AND IN 

EARLY CHILDHOOD. 

In caring for a newborn child not only is the observance of the general 
rules of asepsis from the obstetrician’s viewpoint required, but other mat¬ 
ters of equal importance are involved. The slightest inflammation of the 
eyes should be viewed with suspicion,—particularly if the mother gives a 
history of vaginal discharge,—and should be treated according to indica¬ 
tions. No injury can result from the proper application of the ordinary 

(756) 



THE HYGIENE OF THE EYES. 


57 


4 O 4 


methods of prevention usually prescribed at this period, whereas the gravest 
results may follow a neglect to observe every precaution in this legald. 
The statistics of to-day, compared with those of the past, bear testimony 
to the wisdom of this procedure. 

The infant's eyes should be protected from intense light, and the 100 m 
should never be brilliantly illuminated, although a judicious amount of sun¬ 
light, if properly shaded and not permitted to fall directly into the child s 

eyes, is wholesome and will result in no injury. 

The head of the crib should be turned toward the window or be shaded 
by a canopy. When the child is taken for an airing, the carriage should 
be provided with a sunshade lined with a material of a light-absorbing 
color, such as green, and not, as seems to be the prevailing tendency to-day, 
shaded by a white parasol, or perhaps not shaded at all. 

A child requires change of scene and varied amusement, and foi this 
reason it is most unwise to keep a little one confined to the play-room day 
after day. It should be remembered that the health of the eyes is directly 
dependent upon the condition of the general system, and if the aforesaid 
practice is continued for any length of time, the eyes will suffer. 

Children should not be given small toys or picture-books with which 
to amuse themselves. Often this rule is not easily carried into effect, and 
if this is the case, their use should be limited to as brief a period of time as 
possible. In fact, in pleasant weather it is well to insist that children be 
out of doors as much as possible, for thus they not only receive the benefits 
of fresh air, but they will also enjoy the constantly changing scenes and 
pleasures ; here, too, close vision is not often lequiied. 

Kindergartens, now so popular for the instruction of the very young, 
are a prolific source of injured eyes. Children who attend these schools 
are often obliged to amuse themselves with occupations that have a most 
disastrous effect upon the eyes. These institutions often hold their sessions 
in buildings never intended for that purpose; frequently they are poorly 
lighted and too often improperly ventilated. Situated, as they frequently 
are, in fashionable districts, it is assumed that here the children of wealthy 
parentage may be instructed in the rules of decorum. Unfortunately, this 
system is not limited to the favored classes, but has gained in popularity, 
and has even obtained access into the public schools, where, of course, a 
larger field for injury presents itself. Myopia and strabismus, in partic¬ 
ular as well as many other morbid conditions, are undoubtedly often the 
result of the pernicious influences exerted by the kindergarten system. 

Light.—Inasmuch as great harm is done the eyes by neglect to observe 
the utmost caution regarding proper lighting, the subject becomes one 
of special interest. In spite of the great advances that have been made m 
the world of science in overcoming what was, not so many years ago, almos 
a barbarism, and in consideration of the conditions under which our fore¬ 
fathers labored in their efforts for the advancement of learning, passing from 
the feeble tallow-dip to the dim and uncertain oil-lamp, the existing state 


758 


MODERN OPHTHALMOLOGY. 


of affairs, when it does not receive the aid and benefit of hygiene, is ap¬ 
parently even worse than was that of former days; then, too, the injurious 
influences attendant upon these advances have increased proportionately 
by reason of the greater opportunities afforded. Our exertions should, 
therefore, be doubled in an effort to correct such evils as may arise. 

There are, of course, many conditions which, unfortunately, it is ex¬ 
tremely difficult to remedy, as when persons are obliged to pursue their 
daily occupations in the dim light of stores, workshops, etc., amid poor 
hygienic surroundings. Nevertheless, even when very delicate work is done 
continuously at the near point of vision and with defective lighting, these 
same persons will often, at the close of their working-hours, attempt to 
read a poorly printed newspaper or magazine in a dimly lighted car, and 
upon reaching their homes resume their reading by a poor light until their 
eyes, no longer able to respond to the repeated demands made upon them, 
close in sleep. It would be useless to detail here all the harmful effects 
that result from these practices. 

Nevertheless, in spite of all this, a great many of the existing evils 
in the home and in other places where the attention to hygiene is often lax 
are capable of correction. For example, persons should be cautioned against 
reading by dim light at any time. It is a very common practice to attempt 
to read after dusk, by deficient artificial light, and often by moonlight, 
which is, of course, never sufficiently strong for reading purposes. Bright 
lights should also be avoided, and, although persons are more apt to err 
in the other extreme, only direct sunlight need be excluded. Beflected 
lights, as on the water, or in winter when snow is on the ground, are often 
very irritating to the retina3, and under such circumstances dark glasses 
should be worn. 

When we consider that the definition of an object depends upon the 
amount of light that reaches it, the importance of sufficient illumination, 
when required, is rendered more evident. The object looked at practically 
diminishes in size when the light that reaches it is lessened in amount. 
The inevitable result is that the object is brought closer to the eyes or the 
eyes to the object, as the case may be. This, of course, requires an undue 
effort of accommodation and convergence. 

Although there is no light that is an actual substitute for direct 
daylight, the ingenuity of man has devised many useful substitutes. A 
large number of prismatic devices have been proposed, nearly all hav¬ 
ing in view the same object, and differing only in construction. Their 
purpose is so to bend the rays that the light may be distributed equally 
to all parts of a room instead of being confined to the region of its 
reception. This is generally effected by the arrangement of a series 
of prisms that will reflect the light at any desired angle. These con¬ 
trivances have been made in the form of ornamental windows and shutters 
that serve not only the aforementioned purpose, but also take the place of 
the ordinary shutter. 


THE HYGIENE OF THE EYES. 


759 


Although this subject is probably deserving of more consideration 
than has heretofore been accorded it, artificial illumination, by reason of its 
more elastic practicability and ready adaptation to almost any circumstance, 
demands our attention. The light that most nearly approaches daylight is 
the one that serves the best purpose. No attempt will be made here to 
describe in detail the various merits or faults of the numerous methods of 


artificial illumination, but mention will be made of a few points common 
to the most useful of them. 

The'ideal means of artificial illumination, and the one that is the 
subject of most of the experiments in lighting to-day, is fluorescence ; this 
has the property of giving light with the production of little or no heat. 
For the present, however, we must be content with the various means of 
obtaining the highest degree of incandescence from such llluminants as 
electricity, gas, and oil. This much being granted, it becomes desirable to 
know which of these is the most suitable for any specific purpose. 

Electricity probably furnishes the purest, whitest light of all the 
practical light-givers, and is one of the most valuable means of artificial 
illumination at our command. Among many other advantages that it pos¬ 
sesses it may be said to give a maximum amount of light with a minimum 
amount of heat. It does not vitiate the atmosphere of rooms—a very ob¬ 
jectionable feature in other popular methods; it is convenient, com¬ 
paratively safe, and steady in volume. The naked loop of electnca y 
incandescent fibre possesses properties, however, that, if not removed, may 
considerably impair its usefulness and give rise to conditions under w nc 1 
prolonged near work cannot be maintained. The loop should, there¬ 
fore, be shaded by an appropriately tinted translucent bulb, which, w n e 
it may decrease the brilliancy of the light, will extend the field of illu¬ 
mination over so great an area that but a slight amount of luminosity wi 

be lost. . , . 

The incandescent electric bulb has grown steadily m favor, and nio. t 

laro-e cities, as. well as many suburban towns, are equipped for its service. 
Its'cost grows less each year, and because of its convenience it is deservedly 

a very popular means of artificial lighting. 

The naked arc, or free metallic fluid, which is the most powerful ar 1 - 

ficial illuminant for streets, is generally too powerful for use m buildings, 
and possesses many peculiarities of quality that are very prone to give rise 
to symptoms of asthenopia in those who use it for prolonged periods. 

Gas.— This, the most common artificial illuminating power m cities, 
has proved very valuable, and gives evidence of still further usefulness for 
many years to come. Its disadvantages, however, are that it vitiates ie 
atmosphere, generates excessive heat, and, with old-fashioned burners, 
gives a yell™- light; its volume, too, is affected by the slightest draught. 
With modern burners the value of gas has been greatly enhanced by the 
invention of the incandescent mantle; the light thus produced very nearly 
approaches electricity in quality, giving quite a pure white light. 


7G0 


MODERN OPHTHALMOLOGY. 


Kerosene, the most popular method of artificial illumination in rural 
districts and among the poorer classes in cities, although less convenient than 
electricity and gas, may he said to he the least injurious of all the illu- 
minants. Used in the high-grade, modern lamps, it furnishes the most 
comfortable working light. The lamp should be placed in a well-ventilated 
room, in a proper position, and be correctly toned and well diffused. Oil 
has the disadvantages of giving out heat and vitiating the atmosphere. The 
odor of burning lamps and the trouble incident to keeping them clean are 
added disadvantages. 

Print.—The inferior quality of literature that children are often obliged 
to read, particularly during school-life and at the age when cheap fiction is 
a source of amusement, is one of the most prolific sources of eye trouble in 
later life. Unfortunately, although this period is the most susceptible to 
improper influences, the trouble does not end with youth, but continues 
throughout the life of the individual. Newspapers, the most generally read 
of all literature,—-read by all classes and under all circumstances,—are 
striking examples of poor print. 

Taking into consideration the harmful effects of poor printing on the 
eyes of both old and young, it readily becomes apparent that the proper 
printing of school-books is a subject of the utmost importance, since at the 
school-age many maladies may arise from neglect—diseases that could 
have been prevented by the observance of a few simple rules. School-books 
should be of a size that can easily be handled, and the type should be large 
and distinct. It is not easy to fix a definite size for the letters, as so much 
depends upon their kind and form. If the print is poor and indistinct, the 
book must be held closer to the eyes in reading, and for this an extra effort 
of accommodation is demanded; even if the type is large, if it is not 
printed distinctly the eyes will suffer. Books intended for the use of chil¬ 
dren should, however, be printed in bold-faced type, with black ink of good 
quality; a suitable size of type is that known to printers as ten point, or 
long primer, but if the face of the type is sufficiently heavy, eight point, or 
brevier, may safely be used. Leading— i,e., the spacing between the lines—- 
and spacing between the words are important aids to the eye; the lines 
should be at least two millimetres apart. As the eyes move constantly in 
reading, the external muscles may suffer if the lines are too long; for this 
reason wide pages should be made up of two or more columns, the lines not 
exceeding four inches in length, and the columns separated by a space 
or a rule sufficiently distinct to avoid confusion. The paper should be of 
good quality, and thick enough to obscure the opposing page. The surface 
should be dull, and it has been proposed by some that tinted paper be used. 

Reading.—The eyes, particularly in youth, are greatly injured by the 
demands made upon them by an inordinate amount of incessant and labori¬ 
ous work, the most constant of which is reading. The visual organs are no 
better qualified for constant work than is any other organ of the body, and 
yet how much oftener are they abused! If an individual is fatigued by 


THE HYGIENE OF THE EYES. 


761 


walking, he will, when the opportunity offers, rest; if his arm is wearied, 
he will panse in his work; hut it apparently never occurs to some persons 
that the eyes are just as susceptible to fatigue as is any other part of the 
body, and they are thoughtlessly forced into action until, sooner or later, 
the sufferer is obliged to consult an oculist, who will, of course, attempt to 
correct the refractive error, if such exists. Very often, however, he will 
neglect to ascertain the root of the trouble. Frequently, also, thoughtless 
parents, ambitious to see their children shine in school, m their ardor urge 
prolonged study upon them. Aside from the injury done to the eye itself, 
the brain after a time becomes confused by the close application to reading, 
and although the child may be able to recite his lessons just as he has 
studied them, he frequently does not comprehend what he has learned to 
recite. More valuable and humane would it be if children were gi\ en moie 
oral instruction, their lessons being expounded to them by means of objects 


and illustrations placed at their far point. 

Later in life the eyes should be spared all the continuous work possible, 

and frequently should be rested by shifting from one occupation to 
another, or by closing the eyes at regular intervals for a few minutes 
during the working-hours, in order to allow the ciliary muscles to relax. 
Reading matter that possesses the qualities already described as suitable 
should be preferred; and care should he taken m reading that the book or 
paper be not held too close to the eyes, for, as has been previously said, this 
requires an extra effort of accommodation and convergence. Print that 
cannot be read distinctly at a distance of twenty inches should not be leai 
continuously. Proper illumination is of paramount importance ug i 
should come preferably from the left side, over tlie shoulder; otherwise 
shadows will be formed by the head, shoulders, or hand according to the 
faulty relation of the light. Light situated in front and at a considerable 
distance, unless sufficiently high, should always be avoided, as t us mo 
of receiving light is the most injurious possible. In large office bnil .li „ , 
however, it often becomes necessary to supply each worker-seated at a 
desk for example—with an individual source of illumination II hen t s 
svstem prevails and when the light must be in front of and close to the 
consumer, it should be provided with a shade that will diffuse the light 
upon the object in front of the worker, at the same time proven mg 
glare from entering the eyes. If this is impracticable, an eyeshade should 

be worn which will usually secure the same result. ,1111 4. 

T,^ reader should sit upright, his head erect, '»«mg ffie book almos 
on a level with the eyes; if, owing to the size or weight of the book this 
is not possible, it should be placed on a table or stand, in such a position as to 
procure t ie best result. Stooping postures give rise to congestion of the 
oX tissues, and the faulty relation of the book to the eyes often causes 

fitio-ue of the external muscles of the eye. 

Readme while riding in cars is a habit that should be discouraged, for 
a constant effort of accommodation is required to meet the repeated changes 


762 


MODERN OPHTHALMOLOGY. 


in focus, and the endeavor of the external muscles of the eyes to keep these 
organs fixed upon the lines is very fatiguing; eyestrain is often engendered 
by this all-too-common habit. 

A practice equally as injurious to the eyes as the one just mentioned is 
that of reading while in the recumbent posture. The desire to read during 
convalescence is sometimes irresistible, but should never be encouraged; at 
this time the muscles usually are weak, resistance of the tissues is below 
the normal, and the result of the imprudence may be disastrous. Even in 
health the practice should not be indulged, for it is almost impossible, 
without considerable effort, to hold the book in a comfortable position 
without tiring the external muscles of the eyes; moreover, it must be 
remembered that the recumbent posture favors congestion—a condition, 
of course, that were better avoided. 

Heading while one is drowsy also has a tendency to promote congestion 
by forcing the ciliary muscles to action when they would relax, and the ex¬ 
ternal muscles to work when the eyes would diverge. 


CARE OF THE EYES DURING SCHOOL=LIFE. 

That practically the very existence of a school is dependent upon the 
hygienic conditions that surround it statistics abundantly show. Of the 
many evils of a poorly regulated school system, a discussion of which would 
carry us beyond the limits of this chapter, it may be said that upon no other 
organ of the body are their influences felt more strongly than upon the 
eyes. During the period a child attends school the tissues of the eyes may 
not yet have been fully developed, and it follows that they are less resistant 
to the morbid influences which they too frequently are called upon to en¬ 
counter in the school-room. To these influences may be attributed many 
of the pathologic conditions of the eyes that manifest themselves in later life. 

With the increased demands that modern educational methods make 
upon the youth of our land come greater strain and increased effort, and 
as a natural result the eyes all too often suffer from the effects of overwork. 
In the face of all this it must be said that to the present generation is due 
much credit for improved sanitary conditions and a desire—that in the 
course of time doubtless will be realized—to bestow upon our growing 
youth the highest degree of educational perfection with the least expendi¬ 
ture of physical well-being. 

In qualifying children for school-life the first question that presents 
itself for consideration is: At what age are children most fit, mentally and 
physically, to have thrust upon them the duties of the school-room? Ob¬ 
viously there can be no working rule that can be applied uniformly to every 
case. As in every other avenue of life in which the regulation of the lives 
of others is a feature, the individual, and not the system or class, demands 
our consideration. Into this question should enter the condition of the 
child physically—in particular, as to the state of the eyes and as to its 


THE HYGIENE OF THE EYES. 


7G3 


mental adaptability. It is no uncommon thing for children utterly unfit 
by reason of ill health or faulty vision—for school duties to be permitted to 
attend school; and these unfortunate little ones are often accused of 
mental apathy by the careless instructor or thoughtless parent. 

As a general rule, children are not fitted to enter school until their 
eighth or ninth year. Ordinarily at this age the ocular tissues are well 
formed, and if the child be otherwise physically eligible, he may enter upon 
a well-regulated school course. \\ ith those unfortunates, however, w ho are 
afflicted with some high refractive error, corneal opacities, fundus changes, 
or other infirmity, mental instruction should be deferred and constant use 
of the eyes eschewed until such time as returning health may direct, and 
not until every precaution has been taken to correct any refractive error. 
Increased age brings increased resistance of the ocular tissues, and no 
harm can follow the delay of a year or two in sending the child to school. 
In the meantime instruction may be given at home or in special regulated 
courses at school. Outdoor exercise should be strongly advised. 

The importance of detecting a refractive error and making the needed 
correction cannot be urged too vigorously. The ambitions, the aims, and the 
very conduct of the sufferer's life are all involved. The development of his 
character and the molding of his tastes and proclivities, those features which 
will determine his usefulness in later life, are matters that are implicated. 

The problem of determining upon some rational method for qualifying 
children for school-work now presents itself. It is not necessary for our 
purpose that a new political office be created, or that a skilled oculist be 
elected to fill such office. This duty lies chiefly with parents. When a 
child is deemed ready for school he should be taken to an oculist, who w ill 
advise as to his eligibility. Teachers should be instructed in the methods 
of testing vision, and any child whose visual acuity is found to be below 
normal should be rejected. Moreover, were teachers obliged to make 
these tests yearly, it would not rarely be found that those pupils who at 
the previous examination, gave slow and hesitating answers, were at this 
time unfit for the increased and more difficult studies of the succeeding 
class. These children should receive instruction at home, or their school 
sessions should be shortened until returning health permits a resumption 
of the regular class-work. These methods have been adopted with gratify¬ 
ing results in some schools, simple test-cards having been arranged for this 

* ' Children with inflamed eyes or reddened eyelids should not be admitted 

to school except upon the advice of a physician. The importance of this is 
made manifest when the danger of infection at toilet to which children m 

large schools are subjected is considered. . 

The Construction of School-buildings in Relation to Hygiene. 

construction of school-buildings involves many questions of vital importance. 
Great care is required in the selection of the location of the building and m 
securing proper ventilation, drainage facilities, lighting, etc. 


764 


MODERN OPHTHALMOLOGY. 


Location. —The location of the building should be so chosen as to 
secure the best possible hygienic surroundings. In cities the building 
should not be situated on a narrow street, where sufficient light and ventila¬ 
tion are impossible. Investigation has shown that defective eyesight is more 
prevalent in schools situated on narrow streets and where proper illumination 
is interfered with by high walls, and it has even been observed that pupils on 
the lower floors suffer most from defective vision; hence the value of the 
correct appreciation of this step. The building should be remote from large 
factories where distracting noises are likely to be heard and where offensive 
odors and irritating gases are often prevalent. Provision for suitable 
recreation is highly necessary, and districts where large playgrounds can 
be provided for out-of-door exercise are to be preferred; when this is im¬ 
practicable on account of a lack of sufficient space, a large play-room well 
lighted and properly ventilated should be provided for the amusement of 
the little ones. This will also serve for use on rainy days. 

Light. —The building should be so constructed that light will enter 
directly, and not be reflected by surrounding walls or windows. All parts of 
the room should be evenly and diffusely lighted by skylight. It is im¬ 
possible to err on the side of having too much light, for this can always be 
controlled. Javal insists that every portion of the room should be so flooded 
with light that the darkest places will have sufficient illumination on a dark 
day. A room of oblong shape is usually lighted better than a square room, 
and should receive its light from windows situated at least four feet from 
the floor, so that the light will fall above the heads of the pupils. The light 
should come preferably from the northern side of the room, the northern 
light being the most constant; when, however, sunlight can reach the room 
by a different exposure, this advantage must not be disregarded. Intense 
light may, of course, be controlled by shades or awnings. It is difficult to 
fi x any uniform dimension for the comparative size of windows, as a great 
deal depends upon the direction from which the light enters and upon the 
height of surrounding buildings; in any event, the proportion should not 
be less than one to five. 

The walls and woodwork of the school-room should be painted in some 
light-reflecting color, such as light green, blue, etc. Since the direction of 
the light is just as important as the amount that is received, care should 
be taken that the desks be so situated that the light enters from the left 
and rear; otherwise shadows will be formed by the writer’s head, shoulders, 
or hand; under no circumstances should the light come from the front or 
fall directly into the face of the pupil. 

In working upon an object, it should be remembered that all light that 
docs not come from it can be but a source of annoyance—by irritating the 
eyes if it is direct, or by confusing the image of the object with the images of 
other objects if it is reflected. When light comes from the right side 
as well as from the left, annoying shadows and perverse lights will be 
formed. At times this direction for receiving light cannot be avoided in 


THE HYGIENE OF THE EYES. 


765 


order to allow sufficient lighting and ventilation, and when this is the 
case, the windows should be placed so high that the light may be diffused, 
as much as possible, by the ceiling. Even when this has been done, shadows 
will be formed. 

General Plan of the School-room. —The following dimensions, 
given by Eisley, are adapted for the average school-room, and may be used 
as a general working basis:— 

Feet. 


Height of ceiling.15 

Length of room ..32 

Width of room.24 

Pier, or blank wall, rear of room.4 

Pier, or blank wall, front of room .4 

Space allotted to group of windows.24 

Windowsill from floor (beveled).3 

Top of window from floor.14 

Dimensions of Window. 

Height .11 

Breadth.24 


Window casing beveled to six inches from ceiling. 

Furniture.— One of the most important features that affects the com¬ 
fort and well-being of school-children is the proper construction of the 
school-furniture. 

Desks and Chairs .—The dangers that attend the faulty erection of the 
school writing-desk cannot be too strongly dwelt upon. It is obvious that 
to build desks of a uniform height for the use of children of varying sizes 
must prove harmful. When the seat is too high or the desk too low, the 
child must stoop while at work, and the upright position cannot be main¬ 
tained. This is true also if the desk is placed too far in front of the seat, 
for here again the pupil must stoop over in order to reach the object on 
which he is at work. On the other hand, if the desk is too high for the 
seat, the shoulders are forced upward, in which case the arms do not rest 
upon the desk in the proper position. 

Desks should be so built that when the foot rests squarely upon the 
floor the forearms will rest comfortably upon the top, without forcing the 
shoulders upward or compelling the child to bend over. To accomplish this 
the edge of the desk should be on a line with the seat, the back of which 
should be curved slightly forward; the top of the desk should slope slightly 
downward—about ten degrees toward the pupil. The seat should be as wide 
as the thigh is long, measured from the back to the inner bend of the knee. 
It should be level, slightly grooved to prevent sliding, and low enough to 
allow the foot to rest squarely upon the floor. A better way would be to 
build desks so that they may be adjusted mechanically to the requirements 
of each individual. If desks and chairs are not properly constructed in 
relation to the size of the individual pupil, spinal deformities are apt to 
follow. The stooping posture, moreover, favors the gravitation of blood, 












MODERN OPHTHALMOLOGY. 


7G6 

and congestion of the ocular tissue and the many evils that attend close 
vision follow. 

In spite of all precautions, many children yet exhibit a marked tend¬ 
ency for near-sight. To overcome this many contrivances have been de¬ 
vised from time to time, most of which consist of a rest so constructed as 
to hold the head at the proper reading distance. These contrivances have 
occasionally proved very useful. 

Blackboards, maps, and other objects used for purposes of instruc¬ 
tion should be large enough to be seen distinctly from any part of the 
room, so that pupils will not be obliged to strain their eyes in an attempt 
to discern the characters. They should be placed at the proper height 
(about on a level with the eyes), and opposite the source of light, so as not 
to render the objects obscure by diffusion. Blackboards should be washed 
with a sponge and water, and not be allowed to become gray under the use 
of the ordinary eraser. 

The Work in the School-room. —As has been stated elsewhere, books 
should be of a size that can be easily handled, and may be made according 
to the directions previously given, except that the type may be larger 
where the occasion offers. 

Writing .—This subject has given rise to considerable discussion, but the 
consensus of opinion seems to be in favor of the use of the vertical script in 
the school-room, as this is believed to encourage the upright position. The 
paper should be placed centrally in front of the writer, the ruled lines on 
the paper being parallel with the plane of the body. The surface of the 
paper shoidd be dull, or, as has been proposed, tinted, and black ink should 
be used. 

Slates should be entirely discarded, for, besides being uncleanly, the 
written characters are, for want of contrast, indistinct. 

The work in school should be carefully regulated, and frequent inter¬ 
vals of rest allowed; the occupation should be varied from time to time,and 
it is well occasionally to conduct the instruction by means of conversation, 
demonstrations, and lectures. Final term examinations and prize competi¬ 
tions should be discouraged; these contests usually occur at the end of the 
term, when the child is least prepared physically for them. In place of such 
examinations and competitions the average standing of the pupil in the 
class and the teacher's report of the student’s work during the term, ascer¬ 
tained by unexpected quizzes, should be considered in qualifying the pupil 
for promotion. Here, again, stress must be laid on the importance of 
obtaining a plentiful amount of out-of-door exercise for the child; in fact, 
it is absolutely necessary for the health of the learner that a certain time 
each day be spent out of doors. Oral instruction is preferable to continuous 
book-learning, and should be resorted to whenever practicable. Instruction 
by means of blackboards, maps, and the like is an excellent method of im¬ 
parting information, for the work is thus accomplished without compelling 
the pupil to use his near point of vision. 


THE HYGIENE OF THE EYES. 


7G7 


Study at home should be discouraged, for this is often done under the 
harmful influence of a poor artificial light, with no consideration of the 
correct relation of light to object, and usually with no attempt to assume a 
proper posture while at work. Frequently, too, the work is carried on 
after the child becomes sleepy, an evil that should not be allowed to exist. 
For similar reasons the reading of cheap literature, in the form of “dime” 
novels, etc., should be prohibited. 

THE PREVALENCE OF MYOPIA IN THE PUBLIC SCHOOLS. 

The present system of school-hygiene owes its existence probably to 
the increase of myopia among the pupils in the public schools. This disease 
has furnished a basis of construction as to the hygienic requirements of 
schools. Certainly the disease has been an active incentive to the further¬ 
ance of many investigations, for the rapidity with which the malady has 
increased has been so remarkable and so striking, and the decline after the 
inauguration of proper school-hygiene so very perceptible, that exhaustive 
researches have been instigated and many valuable statistics have resulted. 

As is well known, the eyes of animals and of uneducated races at birth 
are hypermetropic, whereas under the same conditions myopia is almost 
unknown. The statistics of school examinations show that at the beednnino; 
of school-life hypermetropic eyes are more numerous than both emmetropic 
and myopic eyes combined, and with the increase of myopia it has been 
found that the percentage of hypermetropic eyes decreased proportion¬ 
ately, the intermediate emmetropic eyes remaining at about a standstill. 
This would seem to show that the change in refraction is a normal evolu¬ 
tion ; that as the child developed intellectually the eye likewise developed, 
in order to adapt itself to the increased demands made by the higher edu¬ 
cation of the individual. To disprove this theory Risley has shown that 
mjmpia is not a characteristic of the student any more than of the artisan 
whose trade requires accurate near vision, provided only that his work 
was begun early in life. Fie further contends, in refutation of the theory 
that the process is physiologic, that in communities where but slight de¬ 
mand is made upon the near vision the necessity for constant care of 
the eyes is not imperative. He maintains, further, that if children from 
these communities are sent to school or put at work demanding near 
vision, the necessity for preventing injury to the eyes is soon made 
manifest. 

As to the pathologic nature of myopia, it is but necessary to review 
the work of so eminent an authority as Risley. This observer found, in 
the schools of Philadelphia, that GO per cent, of eyes with myopic astig¬ 
matism presented chorioidal atrophies or inflammations, usually at the 
temporal margin of the optic nerve; 87 per cent, exhibited varying forms 
of chorioidal disease; and 70 per cent, were asthenopic. 

The pathologic evolution of myopia,—its direct relation to imperfect 
school-conditions,—although probably well known, may here be briefly 


768 


MODERN OPHTHALMOLOGY. 


described. Leaving emmetropia out of the discussion, let us assume, for 
the sake of illustration, a child with hypermetropic astigmatism laboring 
under the disadvantages of faulty school-influences. In consequence of 
insufficient illumination, defective print, and the like, the approach of the 
object to the eyes is made necessary, or, as is more commonly the case in 
schools, the eyes to the object. This is made easier, at an improperly 
constructed desk, by stooping. The result is an undue effort of accommo¬ 
dation and convergence, with congestion of the ocular tissues. The globe 
is pressed upon by the tense external recti muscles, and the tissues become 
softened by the repeated congestions. Hence elongation of the globe oc¬ 
curs in the direction of least resistance, which is backward. The process is 
further continued by the resultant myopia, the object being necessarily 
brought closer for recognition, requiring increased accommodation, con¬ 
vergence, congestion, etc., and so the process continues, elongation and 
near-sight progressing together. There are probably many more factors 
in the history of this process, not the least of which is heredity, which is 
probably responsible for astigmatism; and the various deformities of the 
skull, which are believed to exert a prominent influence. 

THE INFLUENCE OF INJURIOUS HABITS ON THE EYES OF ADULTS. 

The influence of pernicious habits upon the general system has its 
natural effect upon the eyes, which are often not the least to suffer. A 
discussion of the evils that attend the formation of harmful habits would 
open up an interminable field of reproach. It is sufficient for our present 
purpose to mention here the two practices most common to man, and the 
disastrous effects they exert upon the eyes. 

The use of tobacco, notwithstanding all that has been said and written 
in its condemnation, is, particularly when indulged in moderately, prob¬ 
ably not so harmful to the eyes as we are generally led to believe. The 
smoke is, of course, very irritating to the conjunctivas, and disease of the 
optic nerve lias been ascribed to the toxic influence. In these cases, how¬ 
ever, it will usually be found, upon closer investigation into the history 
of the case, that there are other causative factors that, if not wholly re¬ 
sponsible for the diseased condition, may yet be considered as lending their 
influence to effect harm. Many persons, moreover, possess a peculiar idio¬ 
syncrasy for tobacco. 

What has been said of the hurtful influence of tobacco applies in equal 
degree to the use of alcohol. Even when ingested in small quantities, and 
likewise when used in the various trades, this idiosyncrasy makes itself- 
manifest. 

THE EFFECT OF OCCUPATION UPON THE EYES. 

Occupations requiring exposure are not without their ill effect upon 
the eyes. Among such sufferers may be mentioned cab-drivers, fishermen, 
etc., who are constantly exposed to violent changes in temperature, to winds, 


THE HYGIENE OF THE EYES. 


?G9 


etc. Chemists, owing to the deleterious effects of the irritating gases some¬ 
times present in chemical laboratories, are frequent sufferers. Machinists 
are constant victims of flying particles, and every means should certainly be 
taken to prevent what has long been a prolific source of empty eye-sockets. 

While the writer was an interne in the Wills Eye Hospital of Philadel¬ 
phia more than 2000 cases of foreign bodies in the eye came under his care 
in one year. Of this number, 90 per cent, were men engaged in occupa¬ 
tions in which the eyes were exposed to flying chips of steel, emery dust, 
fragments of stone, etc. Hundreds of eyes are lost yearly in this way—a 
fact doubly to be deplored when it is remembered that the wearing of pro¬ 
tective glasses would furnish an excellent means of prevention. There are 
many other occupations through which the eyes suffer, and among such may 
be mentioned those of dressmakers, watchmakers, engravers, proofreaders, 
etc.; in fact, as has already been stated, any occupation that requires con¬ 
stant near vision will prove injurious. 

Nystagmus may be acquired by the pursuit of certain occupations, and 
is frequently observed in miners—miners’ nystagmus. Nystagmus may also 
occur in others whose duties require them to keep their eyes fixed in abnor¬ 
mal positions for prolonged periods. 

CARE OF THE EYES DURING EPIDEMICS. 

There are-many infectious diseases of the eyes the spread of which 
could be prevented were the ordinary rules of cleanliness strictly observed. 
In the time of an epidemic, or when an infectious disease is known to exist 
in a household, it becomes the duty of the physician to make known its 
presence, in order that he may, so far as lies in his power, protect others 
from infection. When the disease presents itself, the patient should be 
isolated and provided with toilet articles, bed-linen, etc., for his individual 
use. If but one eye is infected, the patient should be warned of the danger 
of autoinfection. All substances used about the affected eye should be 
destroyed—burned, wherever possible. 

THE CARE OF THE EYES IN OLD AGE. 

In the declining years of life the tissues of the eye—like those of 
other organs of the body—become less resistant to disease, and, as a result 
of undue strain, impaired nutrition, or a faulty hygiene, often become the 
seat of serious diseases. One of the most common of these is cataract. 
This affection is rare among those who in youth exercised proper care of 
the eyes, and who, when the necessity arose, were fitted with suitable 
lenses. Once the disease lias become complete, operative procedure is the 
only resource. With the observance of a rigid hygiene, and, if deemed 
advisable, the adjustment of proper correcting lenses, the progress of the 
disease may in many cases be retarded and amelioration of the symptoms 
sometimes follows. 


40 


770 


MODERN OPHTHALMOLOGY. 


As. life progresses the power of accommodation gradually diminishes 
until, when the age of forty or thereabouts is reached, it has almost dis¬ 
appeared. At seventy-five it is usually entirely obliterated. This failure 
of accommodation, known as presbyopia, is the natural result of oncoming 
old age. In this condition, the lens, having lost its elasticity, is pre¬ 
vented from assuming that convexity which is necessary for the act of ac¬ 
commodation. This convexity must, therefore, be supplied by suitable 
glasses. 

In advancing old age the greatest care should be exercised that the 
eyes be not unduly strained by prolonged application to near work. Strong 
lights should be avoided as much as possible and every effort should be 
made to shield the visual organs from the effects of irritating vapors and 
gases. The eyes should frequently be bathed with a solution of boric 
acid,—10 grains to the ounce of distilled water,—the solution being 
applied by means of a pipette or eye-dropper. If glasses are worn, these 
should be kept perfectly clear by repeated washings. It should be borne 
in mind that glasses require frequent adjusting; particularly is this so 
when different glasses are used for reading and for distant vision, the 
frequent interchange rendering this necessary. (See, further, the section 
on “The Care of Spectacles.”) 

CLIMATIC CHANGES IN THEIR EFFECTS UPON THE EYES. 

In judging of the effects of climate upon the eyes it must be borne in 
mind that the eye-tissues, as well as the nasal passages, of some individuals 
are peculiarly susceptible to atmospheric and climatic changes. It seems 
hardly necessary to state that a person so afflicted should, wherever possible, 
take up his residence in a district best suited to his condition. At the first 
premonition of the approach of an attack he should be advised to change his 
place of residence. 

The effects of climatic changes upon the eyes seem to be felt particularly 
in hospitals, among patients whose eye-tissues are in a low state of vitality, 
and hence are more susceptible to such influences. During one outbreak 
of catarrhal conjunctivitis that occurred at Wills Eye Hospital the writer 
observed 19 cases develop within eight hours. This outbreak occurred 
simultaneously on both sides of the house, 12 cases appearing among the 
male patients and 7 among the female, although there was no possible means 
of direct communication between the two departments. These attacks occur 
almost invariably at the beginning of the rainy seasons, particularly in the 
spring and fall. 

It has been noted, during the writer’s observations in the Wills Eve 
Hospital, that, when such an outbreak of catarrhal conjunctivitis occurs 
among the patients, almost every inmate sooner or later succumbs to an 
attack of the disease, varying in intensity from a slight catarrh to quite vio¬ 
lent symptoms. Hence these outbreaks are regarded with a great deal of 
apprehension, for, aside from the discomforts produced by the disease, the 


THE HYGIENE OF THE EYES. 


771 


progress of the healing process is naturally retarded, and as a result of 
repeated attacks a chronic inflammation ensues. 

The disease generally subsides as suddenly as it appeared. The writer 
has also observed the marked tendency of keratitis, conjunctivitis, etc., to 
follow upon climatic changes, and he has noted their influence to affect par¬ 
ticularly the healing process after corneal sections. 

THE CARE OF SPECTACLES. 

When the patient has been fitted with glasses, he should be instructed 
as to the proper method of caring for them, so as to secure the best results. 
He should be told of the necessity for keeping them adjusted accurately, 
and the need for cleanliness should also be dwelt upon. It apparently 
never occurs to some that their glasses require cleaning, and a supposed 
visual defect will often prove in reality to be but a dimness of vision due to 
soiled lgnses. When such glasses are worn persistently, the straining in 
an effort to see may give rise to irritation and inflammation of the eyes. 

In cleaning spectacles the frame should be grasped firmly close to the 
hinge, and not at the bridge. The lenses should then be wiped carefully 
with a clean, unstarched handkerchief, so as to avoid scratching the 
glasses. At least once a week the glasses should be washed in ammonia- 
water, except in the case of bifocal lenses, where this operation would be 
destructive. A fact to be borne in mind is that glasses must be changed 
at stated intervals; frequently, too, they require changing after prolonged 
illness or following severe shock. 


CHAPTER XXV. 


METHODS EMPLOYED IN THE MICROSCOPIC EXAMINATION 

OF THE EYE. 

By W. E. FISCHER, M.D., of St. Louis, 

Instructor in Ophthalmology in the St. Louis College of Physicians and Surgeons; 

Late Voluntary Assistant at the Imperial Royal Eye Clinic of Vienna. 

MATERIAL. 

To obtain - fresh human eyeballs for histologic study is extremely diffi¬ 
cult, as comparatively few pathologic conditions require an enucleation of 
a healthy globe. The chief sources of such eyes are executed criminals, 
retrobulbar and epibulbar tumors, and resections of the. upper jaw. An 
eye enucleated two to three—at the highest four—hours after death is 
scarcely to be utilized for careful histologic research. 

Pathologic material is more readily procured fresh, as the treatment 
often necessitates the removal of the globe or the diseased tissue. Some 
morbid conditions still remain which do not require an enucleation or ex¬ 
cision of the diseased tissue and can consequently be obtained only after 
death. 

Enucleation. —For the technique see page 607. The assistant should 
exercise great caution not to allow the corneal epithelium to dry, nor to 
brush it off by reckless sponging with dr}' gauze. 

Orientation. —The vessel into which an enucleated bulbus is placed 
should be labeled immediately after enucleation. Threads may be passed 
through the tendinous stumps of the internal and external recti muscles. 
But the form and asymmetry of the bulbus, the shape of the cornea, the 
stumps of the tendinous insertions of the ocular muscles, the entrance of the 
two long posterior ciliary vessels, which perforate the sclera on each side 
of the optic nerve in the horizontal meridian, and the eccentric entrance 
of the optic nerve will prove of value in orientation. 

PRESERVATION OF EYEBALLS FOR DEMONSTRATION. 

Dry Method. —Fix the bulbus in formol; then harden and dehydrate 
thoroughly in absolute alcohol, which should be changed a number of times. 
Finally the eye is left in pure turpentine for a week, is then taken out, and 
the superfluous turpentine is allowed to evaporate slowly. Such bulbi will 
keep indefinitely. 

A very good medium is a 4-per-cent, strength formol solution (4 parts 
of formol to 96 parts of water). The cut surface of the eyeball is laid 

(772) 


MICROSCOPIC EXAMINATION OF THE EYE. 


773 


on the bottom of a glass container (made by Wall & Ochs). The glass rod 
in the rubber stopper is pressed down on the spheric side of the eye to hold 
it in place. 

Kaiserling’s Method is admirably adapted to preserve the colors and 
transparency of the ocular structures; it is as follows:— 


Fonnol . 750.0 

Distilled water. 1000.0 

Potassium nitrate . 10.0 

Potassium acetate . 30.0 


The specimens are allowed to remain in this solution for twenty-four 
hours. Transfer to 80-per-cent, strength alcohol for twelve hours. They 
are then placed in 95-per-cent, strength alcohol for two hours. The 
preparations are preserved in a mixture of water and glycerin, equal parts, 
with the addition of 30 parts of potassium acetate. Very delicate objects 
are to remain in this mixture only for from one to two days, and are finally 
preserved in a mixture of equal parts of water and glycerin with the addi¬ 
tion of a little absolute alcohol (1 to 10). 

Method of Priestley Smith.—The eye is bisected, preferably after it 
has been frozen. The yellow stain imparted to a specimen fixed in Muller's 
fluid may be removed by placing it in a 5-per-cent, strength solution of 
chloral hydrate, which is renewed every two or three days until the solu¬ 
tion no longer becomes tinged. 

Now place the preparation successively in 10-, 25-, and 50-per-cent, 
strength glycerin solutions, allowing it to remain for twenty-four hours in 
each. Preserve the specimen in a jelly consisting of:— 

Best French gelatin (Coignet & Co., Paris). 1.0 

Water . 6.0 

Glycerin . 6.0 

The gelatin remains in the water until it swells, and is then melted 
by gently warming; now add the glycerin and a few drops of carbolic acid 
or thymol. Filter through flannel while warm. 


Method of Nettleship.— 

Glycerin . 

Gelatin . 

Creosote . 


250.0 

250.0 

1.0 


« 

All the interstices of the preparation are filled with the mixture, and 
then the air-tight jar is filled with the jelly and sealed. 


FIXING. 

The object of fixation is to retain the tissue-elements in the condition 
which the tissue presented in life or at the moment of death, and to pre¬ 
vent further postmortem changes. Most of the fixing fluids coagulate the 
albumin, while others dehydrate. 












77 4 


MODERN OPHTHALMOLOGY. 


Muller’s Fluid (Introduced by H. Muller).— 


Potassium bichromate .^. 2.5 

Sodium sulphate . LO 

Distilled water. 100.0 


The fluid must be used in considerable quantities and renewed daily 
until it no longer becomes cloudy. For thorough fixation a period of six 
weeks at the temperature of the room (70° F.) will be required. By plac¬ 
ing the specimen in an incubator at a temperature of 36° to 40° C. and 
changing the fluid daily fourteen days will suffice. To prevent the develop¬ 
ment of fungi a little camphor or carbolic acid may be added. Virchow 
recommends keeping the specimen in the dark to prevent the formation of 
precipitates in the tissues. 

When fixation is complete the specimen is to be washed in flowing water 
for twenty-four hours and then is hardened in alcohol of increasing con- 
centration (see page 777). Muller’s fluid enjoyed great popularity among 
ophthalmologists, hut it has been partly superseded by formol, sublimate, 
and picric acid-sublimate, which are sometimes preferred. A specimen 
should be fixed, hardened, and stained in accordance with the peculiarities 
sought for. 

Formol. —Formol, or formalin, is an aqueous solution containing 40 
per cent, of formaldeliyd-gas. It is used in strengths of 4 to 10 per cent. 
An ordinary working solution is:— 


Formol . 10.0 

Distilled water . 100.0 


The above solution fixes in from twelve to twenty-four hours. 

If the eyeball be left in formol too long the lens and sclera get very 
hard. A 4-per-cent, strength formol solution is a suitable agent to preserve 
eyes which are intended for museum purposes. 


Formol-Muller Fluid.—- 

Potassium bichromate . 2.5 

Sodium sulphate . 1.0 

Formol . 10.0 

Distilled water . 100.0 


Or to 100 cubic centimetres of Muller’s fluid are added 10 cubic centimetres 
of concentrated formol solution. The specimen is fixed in from six to 
fifteen hours. Wash in flowing water for twenty-four hours. The formol 
is preferably added immediately before the solution, is used, since the 
mixture loses its efficacy in a week. 

Absolute Alcohol is not a good fixing agent for the eyeball, which it 
shrinks too much. The finer structures are not well preserved. It answers 
very well where we wish to examine for tubercle bacilli or leprosy bacilli. 


Erlitzki’s Fluid.— 

Potassium bichromate . 50.0 

Copper sulphate. 10.0 

Distilled water . 1000.0 














MICROSCOPIC EXAMINATION OF THE EYE. 


This fluid fixes more rapidly than Muller's fluid. Ten days at the tem¬ 
perature of the room or four days in an incubator are sufficient. The eye¬ 
ball is then to be thoroughly washed in water for twenty-four hours. 
Erlitzki’s fluid is similar to Muller’s fluid, but it produces more shrinking 
and more precipitates. 

Sublimate.— 

Corrosive sublimate, saturated solution, 

Alcohol, 95-per-cent, strength.of each 100.0 

The eyeball remains in the solution for twenty-four hours. It is then 
washed thoroughly in flowing water and finally is transferred to a brown- 
red solution of iodin in 70-per-cent, strength alcohol, which must be changed 
until it retains its brown-red tint. The iodin removes the sublimate crys¬ 
tals which were precipitated in the tissues. Sublimate is an admirable 
fixing agent for the preservation of karyomitotic figures. 

Flemming's Solution.— 

One-per-cent, strength chromic acid . 15-0 

Two-per-cent, strength osmic acid. 4.0 

Glacial acetic acid... 1-0 

Allow the preparation to remain in this solution for at least twenty- 
four hours. This is a splendid medium for fixing the retina, the vitreous 
body, karyomitotic figures, and fat. 

' Other fixing agents are: picric acid, sublimate-picric acid, 3-per-cent, 
strength nitric acid, osmic acid, etc. 

WASHING. 

Specimens that have been fixed in Muller’s fluid, in picric acid, or in 
Erlitzki’s fluid should be washed in flowing water for twenty-four hours. 
The specimen may be placed in a jar into which a small rubber tube hangs 
from the faucet. If the specimen is small, a piece of gauze may be tied over 
the top of the jar to prevent it from getting lost. If a hydrant is not con¬ 
venient, a large jar in which the water is frequently renewed will answer as 

well. 

DECALCIFICATION. 

In certain instances calcification or ossification renders the sectioning 
with the microtome difficult or impossible. In order that sectioning may 
be done the specimen must be decalcified. Lime deposits may occur in 
all portions of the eye. Perichorioidal ossifications are very common 
after inflammations. Calcareous deposits are frequent in gliomata of the 
retina, and ossifications in sarcomata of the chorioid have been occasionally 

observed. 

The best fluids for decalcification are:— 

1 Muller’s Fluid._Muller’s fluid will decalcify, provided the speci¬ 

mens be left in the solution long enough. It decalcifies very slowly, and it 
will be necessary to permit the specimens to remain in it for months. 






MODERN OPHTHALMOLOGY. 


1 i 


G 


2. Picric Acid.—Picric acid in a concentrated aqueous solution decal¬ 
cifies slowly because it does not penetrate into the tissues deeply. The 
same is true of picro-nitric acid. 

3. Method of Haug.—This method is well adapted to decalcify the 
tissues of the eye, especially if the specimens have been fixed in formol or 
sublimate. 


Nitric acid . 


.. . 3.0 to 9.0 

c. 

ems. 

Absolute alcohol . 


70.0 

e. 

cms. 

Distilled water. 


30.0 

c. 

eras. 

Sodium chlorid . 

’ 

0.25 

c. 

cm. 

4. Phloroglucin Method.— 

Phloroglucin . 




1.0 

Nitric acid. 




5.0 

Alcohol . 




70.0 

Distilled water. 




30.0 


The above solution decalcifies rapidly. The time required for com¬ 
plete decalcification varies with the amount of calcareous material to be 
removed and the thickness of the specimen. To ascertain if the decalci¬ 
fication is complete, we prick the area of the deposit with a teasing needle. 
After the calcareous deposit has been removed, the specimen should be 
washed in water for several days. 

If the condition remained unnoticed until the specimen was mounted 
for sectioning, it should be placed in equal parts of absolute alcohol and 
ether to dissolve the celloidin and then should be decalcified. 

BLEACHING. 

In order to render the examination of the minute details of some 
normal and pathologic ocular tissues possible, the pigment which is natu¬ 
rally present must be removed. Among the bleaching methods are the 
following:— 

Hydrogen Peroxid.—The celloidin sections are washed in water and 
are then placed in peroxid of hydrogen and are exposed to the sunlight for 
two or three days until they are sufficiently bleached. The sections become 
brittle by this process, but they will stain well. 

Chlorin.—The c-hlorid of lime or chlorin-water may be used, but they 


also make the sections fragile. 

Griffith's Method- 

Potassium chlorate. 1.0 

Concentrated hydrochloric acid. 2.0 

Distilled water. 300.0 


The mixture must be shaken from time to time and should remain 
in the dark. 

Alfieri's Method.—1. Place the section's in a potassium-permanganate 
solution (1 to 2000) for twenty-four hours. When exposed to sunlight, the 
sections assume the brown color in less time. 













MICROSCOPIC EXAMINATION OF THE EYE. 


777 


2. Transfer the brown sections to a solution of oxalic acid (1 to 300), 
which fully bleaches them in a few seconds. 

The sections will be fragile. After all bleaching processes the speci¬ 
mens do not stain as well as unbleached sections; hence they must be left 
in the stains longer. 

HARDENING. 

After the eyeball is fixed and washed and eventually decalcified, it is 
ready to be hardened. M e usually employ alcohol in increasing concentra¬ 
tions for this purpose as follows:— 

The eye is placed in alcohol: 70-per-cent, strength for twenty-four 
hours, 80-per-cent, strength for twenty-four hours, 90-per-cent, strength for 
twenty-four hours, 95-per-cent, strength for twenty-four hours, and in abso¬ 
lute alcohol for forty-eight hours. 

For practical purposes it will suffice if the eye be placed in 70-per-cent, 
strength, in 90-per-cent, strength, and in absolute alcohol. The percentage 
of dilute alcohol need not be absolutely accurate. It may be roughly made 
as follows:— 

70-per-cent, strength alcohol = 74 c. cnis. of 95-per-cent, strength alcohol +26 c. cms. of distilled water. 

SO-per-cent. strength alcohol = 84 c. cms. of 95-per-cent, strength alcohol + 16 c. cms. of distilled water. 

90-per-cent, strength alcohol = 95 c. cms. of 95-per-cent, strength alcohol + 5 c. cms. of distilled water. 

The absolute alcohol should be changed once after twenty-four hours. 

CUTTING THE EYEBALL PREPARATORY TO MOUNTING. 

The eye is ready to be cut for mounting when it has been sufficiently 
hardened. The sections are cut according to the condition for which we 
desire to examine. The globe may be cut in quadrants (a very convenient 
form), one section being made in the vertical meridian and the other in the 
equator. If the lens is to be kept in place, the eye may be capped in a 
horizontal direction above and below the lens. In cases in which the dis¬ 
placement of the lens is a matter of indifference the bulbus may be divided 
in the horizontal meridian into an upper and lower half. If a tumor is 
present, we may divide the globe in the meridian in which the growth is 
situated. 

IMBEDDING. 

Celloidin Imbedding.—Specimens that have been hardened and cut 
must be imbedded in some solid material in order to render sectioning with 
the microtome possible. Celloidin imbedding, proposed by Schieferdecker, 
was first applied for imbedding eyes by Becker, and is practically the best 
method. Celloidin (Schering) is obtained in sealed bottles. Thick cel¬ 
loidin is made by allowing a sufficient amount of celloidin to dissolve in 
equal parts of absolute alcohol and ether to make a fluid the consistency 
of thick syrup. Thin celloidin is obtained by further diluting thick cel¬ 
loidin with equal parts of absolute alcohol and ether until it is a thinner, 
less viscid fluid resembling collodion. 


MODERN OPHTHALMOLOGY. 


ry rvQ 
i i O 

After the globe has been hardened and dehydrated in absolute alcohol 
it is placed in an absolute alcohol and ether mixture, equal parts, for 
twenty-four hours. It is then put in thin celloidin for from four days to 
two weeks. The longer the specimen remains in the thin celloidin, the more 
thoroughly its tissues will be permeated by it. It is finally transferred to 
the thick celloidin and left in it for the same length of time, when all is 
ready for mounting. 

For the purpose of mounting, the specimen is placed in a glass vessel 
deep and wide enough to allow at least one-fourth inch space on all sides. 
The specimen is put in the centre and the thick colloidin is poured on until 
it rises one-fourth inch or more above the specimen. The vessel is then 
covered with a small bell-jar, and the alcohol and ether are allowed to 
evaporate very slowly in a cool place. The celloidin is permitted to harden 
until it has the consistency of wax: i.e., to a degree that an impression with 
the finger-tip (not the nail) can scarcely be made. This usually requires 
from two to four days, depending on the rapidity of evaporation, etc. 

The firm celloidin is loosened by passing a knife along the walls of the 
vessel, and its contents are expelled by gently tapping on the bottom. The 
superfluous celloidin is trimmed off, and the specimen (inclosed in cel¬ 
loidin) is then placed in 70-per-cent, strength alcohol for twenty-four 
hours, when it will be sufficiently hardened to be mounted on a block of 
wood, cork, iron, or stabilit (insulating fibre) which fits the microtome- 
clamp. Thick celloidin is spread on one surface of the block of wood or 
cork and the celloidin block, with its inclosed specimen, is gently pressed 
on it. After ten minutes the wood and the celloidin block are immersed 
in 70-per-cent, strength alcohol and left in it for a number of hours, when 
all is ready for sectioning with the microtome. 

Paraffin Imbedding briefly consists of the following steps:— 

1. Thorough dehydration of the specimen in absolute alcohol for from 
five to twenty-four hours. 

2. Place in xylol for from one-half to four hours. 

3. Place in xylol-paraffin (concentrated solution of paraffin in x}dol) 
for from one to six hours. 

4. Melted soft paraffin (42 degrees) for from one-half to two and one- 
half hours. 

5. Melted hard paraffin (58 degrees) for from one-half to two and one- 
half hours. 

G. Place the specimen in a mold and pour on 58-degree paraffin and 
allow to cool. 

7. Mount on a block which fits the microtome-clamp. 

The above method is admirable for the retina, chorioid, etc., but if it 
be used for a globe the lens must be removed from the eye. 

Paraffin sections are mounted by spreading a drop of water containing 
a trace of alcohol on a slide, on which the section is now laid. The slide 
may be warmed until the water has evaporated; or the slides may be 


MICROSCOPIC EXAMINATION OF THE EYE. 


779 


placed in an incubator and kept at a temperature of 30° to 35° C. for from 
twelve to twenty-four hours. If the specimen has been fixed in Muller’s 
fluid, chromic acid, or osmic acid, the sections are preferably fixed on the 
slide with a mixture of the filtered white of an egg and an equal quantity 
of glycerin to which a few grains of sodium salicylate or a trace of thymol 
have been added to prevent the growth of fungi. 

A drop of this mixture is put on the slide and the technique for 
mounting the section on the slide is the same as for the water with a trace 
of alcohol. 

The paraffin must be removed from the mounted paraffin sections 
before they will accept any stain. This is accomplished by placing the 
slide on which the section has been fastened in a vessel containing pure 
xylol. Then the xylol should be removed with absolute alcohol; if aqueous 
solutions of the stains are to be used, the section is next transferred to 
90-per-cent, strength alcohol, then to 60-per-cent, strength alcohol, and 
finally to water, when it is ready to be stained. 

4 

CUTTING THE SECTIONS. 

The specimen-block should be clamped firmly in the microtome. In 
cutting specimens that have been mounted in celloidin the microtome- 
knife should be set at as acute an angle as possible, in order to utilize as 
much of the cutting edge of the blade as we can. The knife should be 
drawn slowly and evenly to obtain sections free from tears and of a uniform 
thickness. The blade and the specimen should be kept well moistened 
with 80-per-cent, strength alcohol to keep the specimen from drying, and 
to permit the sections to float on the knife. The specimens may be washed 
in water and then stained, or they may be preserved in 80-per-cent, 
strength alcohol. 

In cutting paraffin sections the knife is not placed at so sharp an angle 
and the sections are cut dry. If ribbon sections are to be cut, the knife is 
set at right angles to the direction in which it moves, and the paraffin 
should be quadrilateral. The sections are prevented from rolling up and 
are removed from the knife with a fine camel-hair brush or a delicate 
bristle. If the sections should be wrinkled, they may be placed in tepid 
water, when they will flatten out. 

5TAINING. 

NUCLEAR STAINS. 

1. Hemalaun of P. Meyer.—One gram of hematein is dissolved in 50 
cubic centimetres of 90-per-cent, strength alcohol by warming. This is 
added to a solution of 50 grams of alum in 1000 cubic centimetres of dis¬ 
tilled water. A crystal of thymol may be added to prevent the growth of 
fungi. 

Staining. —1. Wash the sections in water. 

2. Stain for from five to fifteen minutes. 


7S0 


MODERN OPHTHALMOLOGY. 


3. Wash in water for from ten to twenty minutes. 

4. Dehydrate in 95-per-cent, strength alcohol. 

5. Clear in carbol-xylol. Balsam. 

2. Delafield’s Hematoxylin.—Four hundred cubic centimetres of a con¬ 
centrated aqueous ammonic-alum solution is mixed with a solution of 4 
grams of hematoxylin in 25 cubic centimetres of absolute alcohol. The 
mixture is exposed to the light in an open vessel for three or four days; 100 
cubic centimetres of methylic alcohol and 100 cubic centimetres of glycerin 
are then added, and the stain is allowed to mature. In a few days it is 
filtered and is ready for use. 

Staining. —1. Sections are washed in water (or 1-per-cent, strength 
alum solution). 

2. Sections are stained for from two to three minutes; if the stain 
has been diluted with water, ten to fifteen minutes. The section should 
have a light-blue tint, not an intensely dark one. 

3. Wash in water until no more blue color is given off (for from ten 
to fifteen minutes to several hours). 

4. Dehydrate in 95-per-cent, strength alcohol. 

5. Clear in carbol-xylol. Balsam. 

If a section has been overstained in hemalaun or hematoxylin, the 
desired tint may be obtained by the following procedure: Place the over¬ 
stained section in 1 / 10 -per-cent. strength muriatic acid until it turns red, 
then wash the section thoroughly in water for several hours. Should the 
section be still overstained, the procedure can be repeated until the proper 
tint is obtained. 

3. Alum-carmin (Grenacher).—Boil 1 gram of earmin in 100 cubic 
centimetres of a 5-per-cent, strength alum solution for twenty minutes; 
when the solution is cool, filter it. 

Staining. —1. Wash in water. 

2. Stain in earmin for from ten minutes to several hours (this earmin 
does not overstain). 

3. Wash in water. 

4. Dehydrate in 95-per-cent, strength alcohol. 

5. Carbol-xylol. Balsam. 

4. Borax-carmin (Grenacher), Aqueous Solution.— 


Carmin . 0.5 

Borax . 2.0 

Distilled water . 100.0 


The above ingredients are mixed and boiled, and 5 cubic centimetres of 
a 5 / 10 -per-cent. strength solution of acetic acid are added, drop by drop, 
while the mixture is being constantly stirred until it turns to a deep-red 
color. Filter the solution after twenty-four hours. 

Staining.— 1. Wash in water. 

2. Stain in carmin for from five to twenty minutes. 





MICROSCOPIC EXAMINATION OF THE EYE. 


781 


3. Differentiate in hydrochloric acid-alcohol (concentrated hydro¬ 
chloric acid, 1.0; alcohol, 70-per-cent, strength, 100.0). 

4. Wash thoroughly in water. 

5. Alcohol, carbol-xylol. Balsam. 

5. Borax-carmin (Grenadier), Alcoholic Solution.—The alcoholic solu¬ 
tion is used if the sections are not to be brought in contact with water. It 
is prepared as follows:— 


Carmin . 2 to 3 

Borax . 4 

Distilled water . 93 


After forty-eight hours the above solution is mixed with 100 cubic centi¬ 
metres of 70-per-cent, strength alcohol. Allow the mixture to stand for 
thirty-six hours’ time and then filter it. Nuclei stain red with this solution. 

Staining. —1. Transfer the section directly from 70-per-cent, strength 
alcohol into the alcohol-carmin and stain for from five to twenty minutes. 

2. Differentiate in hydrochloric acid, 1.0; alcohol, 70 - per - cent, 
strength, 100.0. 

3. Wash in 70-per-cent, strength alcohol for several hours. 

4. Dehydrate in 95-per-cent, strength alcohol. 

5. Carbol-xylol. -Balsam. 

6. Lithia-carmin (Orth).—Dissolve 2.5 grams of carmin in 100 cubic 
centimetres of a cold, saturated solution of litliia carbonate. 

Staining. —1. Wash the sections in water. 

2. Stain in the solution for from five to ten minutes. (By warming 
gently over the vapor of a water-bath two to five minutes will suffice.—Ober- 
steiner.) 

3. Differentiate in hydrochloric-acid alcohol as before. 

7. Safranin (Pfitzner).—This is an admirable stain for specimens that 
have been treated with Flemming’s solution. 


Safranin .'.. 1.0 

Absolute alcohol. 100.0 

Distilled water. 200.0 


Dissolve the safranin in alcohol and then add the water. Stain the 
sections in this stain from tw r o to twenty-four hours. If the specimens 
have been fixed in Flemming’s solution and the sections stained with 
safranin and treated with acid-alcohol (8 drops of hydrochloric acid or 10 
drops of a concentrated solution of picric acid to 100 cubic centimetres of 
alcohol), until the cclloidin is colorless, the chromatin of the nuclei only 
will be stained. Absolute alcohol. Xylol. Canada balsam. 

Karyomitotic figures are stained intensely red; the nuclei at rest are 
pale pink. Mucin appears yellowish red, while fibrin takes a deep-red tint. 

8. Fuchsin (Rubin).—This stain is prepared and used like safranin. 









782 


MODERN OPHTHALMOLOGY. 


PROTOPLASMIC STAINS. 

The basic anilin dyes stain the nuclei, while, on the other hand, the 
acid anilin dyes stain the protoplasm diffusely. The latter are seldom 
employed alone, hut are nearly always combined with a nuclear stain. 

1. Eosin (Fischer).— 

Eosin . 1.0 

Water . 100.0 

Staining.—T his solution may be diluted from three to five times 
with water. 

1. Place the section in the diluted stain for from three to five minutes; 
in some instances one minute will suffice. 

2. Wash in water for a few minutes. 

3. .Dehydrate the sections in 95-per-cent, strength alcohol. 

If the section should have been overstained it may he left in 70-per¬ 
cent. strength alcohol until the excess of the eosin has been extracted. 

One-per-cent, strength eosin in 90-per-cent, strength alcohol may also 
be employed. Stain the same as above with the exception that the speci¬ 
men is transferred from the stain directly to alcohol. 

2. Picric Acid may be used as a counterstain in a concentrated aqueous 
or alcoholic solution. In certain instances it may be still further diluted 
before using. Should the tissue be overstained, the excess can be removed 
by washing in water or alcohol. If picric acid is used as a counterstain 
with hematoxylin or with hemalaun, the tissue must be slightly over¬ 
stained, as picric acid will extract them. 

3. Orange G, in a dilute aqueous solution (1-per-cent.), stains the 
protoplasm light orange. 

4. Acid Fuchsin (Fuchsin S., Rubin S.) is used as a concentrated aque¬ 
ous solution, or it is dissolved in anilin-water. It readily overstains, and 
this fault cannot be remedied. 

DOUBLE STAINS. 

The following combinations of nuclear and protoplasmic stains pro¬ 
duce good results:— 

Hemalaun or hematoxylin and eosin. Carmin and orange G. 

Hemalaun or hematoxylin and orange G. Carmin and picric acid. 

Hemalaun or hematoxylin and picric acid. Safranin and picric acid. 

Hemalaun-eosin is a durable stain and the best for all practical pur¬ 
poses. 

Staining. —1. Stain in hemalaun for from five to ten minutes (see 
hemalaun). 

2. Wash in water for from ten to thirty minutes. 

3. Stain in a diluted 1-per-cent, strength aqueous solution of eosin 
or in an alcoholic solution for from one to five minutes. (The alcoholic 
solution is composed of: eosin, 0.1; alcohol, 90-per-cent, strength, 100.0.) 




MICROSCOPIC EXAMINATION OF THE EYE. 


783 


4. W ash in water for a few minutes. 

5. Alcohol, 95 per cent. Should the specimen be overstained in eosin, 
it may be placed in 70- to 80-per-cent, strength alcohol until sufficient eosin 
has been extracted to give the section a rose-red tint. 

6. Carbol-xylol. 

7. Balsam and cover-glass. 

Van Gieson's Stain is a beautiful tricolor stain, but unfortunately it is 
not always permanent. 

1. Overstain section in hematoxylin for from fifteen to thirty minutes. 

2. Wash thoroughly in water. 

3. Stain for from one to three minutes in a concentrated aqueous solu¬ 
tion of picric acid, to which sufficient aqueous concentrated solution of acid 
fuchsin has been added to give a deep-red color. 

4. Wash in water for one-half minute. 

5. Alcohol, with a trace of picric acid. 

6. Carbol-xylol. Balsam. 

The above is an admirable stain for the optic nerve. With this stain 
colloid bodies assume an orange-red tint, while hyalin bodies are bright red. 

Weigert’s Stain for Medullary Nerve-sheaths.—Specimens that have 
been fixed in Muller’s fluid, Erlitzki’s fluid, or 5-per-cent, strength potas¬ 
sium-bichromate solution are not washed, but are rapidly hardened in alco¬ 


hol, imbedded in celloidin, and sectioned. 

The sections are placed in:— 

Saturated solution of neutral copper acetate. 50.0 

Distilled water . 50.0 


for from twelve to twenty-four hours. 

They are then transferred to a solution composed of:— 


(a) Hematoxylin . 1.0 

Absolute alcohol . 10.0 

(b) Lithia carbonate . 10 

Distilled water . 100.0 


where they remain for from twenty minutes to twenty-four hours. It is 
preferable to keep the solutions a and b separate or mix the quantity one 
wishes to use in the proper proportions immediately before staining. 

When the sections are black they are washed and differentiated in:— 


Borax . 2.0 

Ferricyanid of potassium. 2.5 

Distilled water . 100.0 


The latter solution may be diluted with water to one-half its strength, 
so that the process of differentiation may be better controlled. If the stain¬ 
ing is successful, the nerve-sheaths will appear dark blue, the degenerated 
areas, as well as the remaining tissue, light brown. Blood and fibrin often 
take a dark-blue tint. 











784 


MODERN OPHTHALMOLOGY. 


Method of Marchi.— 1 . Fix in Mullers fluid for at least eight days. 

2. Transfer to a freshly prepared mixture of equal parts of Muller’s 
fluid and osmic acid for from six to twelve days. 

3. Wash in flowing water for twenty-four hours. 

4. Harden in alcohol; celloidin. Section with the microtome. 

5. Stain the sections in lithia-carmin for contrast. 

Degenerated areas appear black, everything else light yellow. 

Other methods are those of Poland Kulschitsky. For their execution 
the reader is referred to the special works of Greeff or Seligmann. 

DEHYDRATION OF THE SECTIONS. 

Paraffin sections are placed in 60-per-cent, strength alcohol for a few 
minutes, then in 90-per-cent, strength alcohol, and finally in absolute 
alcohol. 

Celloidin sections are dehydrated in 95-per-cent, strength alcohol, 
since absolute alcohol dissolves the celloidin. If the celloidin has stained 
as intensely as the tissue,—for instance, after staining with anilin dyes,— 
it may occasionally he necessary to remove the celloidin. This is accom¬ 
plished as follows: The section is treated with absolute alcohol for about 
five minutes and then is placed in a mixture of absolute alcohol and ether 
(equal parts) for from ten to fifteen minutes. Oil of cloves will also dis¬ 
solve the celloidin, but it must be removed again by pure xylol. 

CLEARING OF THE SECTIONS. 

Paraffin sections that have been thoroughly dehydrated with absolute 
alcohol are then treated with xylol, in which they will clear in a few 
minutes. 

Celloidin sections that have been dehydrated only in 95-per-cent, 
strength alcohol are preferably placed in carbol-xvlol for clearing. Carbol- 
xylol is an excellent clearing agent, and is prepared as follows:— 


Pure xylol. 45.0 

Crystallized carbolic acid. 15.0 


In place of xylol or carbol-xylol, origanum-oil, oil of bergamot, oiL of 
cedar, or oil of lavender may be employed. Oil of cloves is rarely used for 
the purpose of clearing celloidin sections, as it dissolves the celloidin and 
extracts most of the anilin dyes. 

MOUNTING THE SECTIONS ON SLIDES. 

After a celloidin section has been cleared it is spread smoothly on the 
slide. When all wrinkles have been brushed out with the teasing needle, 
the clearing medium is blotted off by firmly pressing the section to the 
glass with several layers of fine filter-paper. How put 1 drop of Canada 
balsam on the section and place the cover-glass on it. 

For paraffin sections the process is the same, with the exception that 
the section is fixed to the slide and the process is carried out on the slide. 




MICROSCOPIC EXAMINATION OF THE EYE. 


785 


Sections that are not to be brought in contact with alcohol after they 
have been stained are mounted permanently in glycerin. The section is 
placed on the slide, the water is blotted with filter-paper, and then 1 drop 
of glycerin is put on the section, when the cover-glass is gently placed on it. 

In order to keep such a preparation permanently the edges of the 
cover-glass must be fastened to the slide by rimming the cover-glass with 
cement. Superfluous glycerin about the edges of the glass must be re¬ 
moved with cotton moistened with alcohol. The cover-glass may be 
fastened to the slide by painting the edges with melted paraffin over 
v hich a coat of asphalt varnish is then applied. Kroenig’s cement may be 
also used. 

DEMONSTRATION OF DEFINITE SUBSTANCES AND TISSUE= 

ELEMENTS. 

Nuclear and Protoplasmic Structures. —(A) Nuclear Structures. 
( a ) Flemming’s solution, (b) Sublimate or formalin fixation should be 
used. This method is applicable for demonstrating the structure of the 
nucleus. 

Fix in Flemming’s solution and imbed in paraffin. 

1. Stain in safranin (page 781). 

2. Stain in a 2-per-cent, strength gentian-violet solution. Differenti¬ 
ate as with the safranin. 

3. Gram’s Method (see page 791). —Anilin-water and gentian-violet 
(from three to five minutes). Treat with a solution of iodin, 1.0; potas¬ 
sium iodid, 2.0; water, 300.0, for from one to two minutes. 

4. Decolor in absolute alcohol. 

5. Stain in carbol-fuchsin:— 

Five-per-cent, strength aqueous carbolic-acid solution.. 100.0 


Fuchsin. 10 

Alcohol . 10.0 


Stain in this solution for one-half hour, then rinse in 90-per-cent, 
strength alcohol. 

6. W ash in hydrochloric acid-alcohol (see page 781) or 1-per-cent, 
strength picric-acid solution for from one-half to two hours. 

7. Wash in absolute alcohol until only slight stains are imparted to 
the alcohol. 

Clear in xylol. Balsam. 

Ixaryomitotic figures are intensely red; nuclei at rest have a pale- 
red tint. 

(B) Protoplasmic Structures. —Altmann recommends the follow¬ 
ing method for the demonstration of the granules in the cell:— 

1. Fixing in a solution of:— 

Five-per-cent, strength potassium bichromate, 

Two-per-cent, strength osmic acid.of each, equal parts. 

2. Wash in water and harden in alcohol of increasing concentration. 


SO 





786 


MODERN OPHTHALMOLOGY. 


3. Imbed in paraffin. Cut sections three to five micromillimetres. 
Mount and remove paraffin. 

4. Stain in a solution of 


Anilin-water . 100.0 

Acid fuchsin . 20.0 


Warm until the solution begins to steam. 

5. Allow to cool and remove the surplus of the stain with a mix¬ 


ture of:— 

Concentrated alcoholic solution of picric acid. 1.0 

Water .. 2.0 


Eenew the picric-acid mixture and keep the same at a temperature of 
42° C. for from thirty to sixty hours. 

Wash in absolute alcohol, xylol, and balsam. 

The red granules are easily recognized in the pale-yellow cell-body. 


Elastic Fibres.— Method of Weigert.— 

One-per-cent, strength aqueous solution of fuchsin rubin.. 100.0 
Two-per-cent, strength aqueous solution of resorcin. 100.0 


are mixed in a porcelain dish and brought to the boiling-point. To this 
solution are added 25 cubic centimetres of liquor sesquichlorati (Ph. G-.) and 
the mixture is boiled for two or three hours. A precipitate is formed. The 
solution is-allowed to cool and is then filtered; the filtrate is rejected. The 
precipitate on the filter-paper is now boiled in 200 cubic centimetres of 94- 
per-cent. strength alcohol; the solution is again allowed to cool, and finally 
is made up with alcohol to 200 cubic centimetres; 4 cubic centimetres of 
hydrochloric acid are added, whereupon the stain is ready for use. This 
stain may be purchased of Dr. Grubler, in Leipsic. 

Liquor ferri sesquichlorati is made as follows: 1 part of iron is dis¬ 
solved in 4 parts of hydrochloric acid, and then there are added, for every 
100 parts of iron dissolved, 260 parts of hydrochloric acid and 135 parts of 
nitric acid. 

Staining. —1. Stain the section in carmin. 

2. Differentiate in hydrochloric acid-alcohol. 

3. Wash in alcohol. 

4. Now stain the sections in Weigert’s elastic-fibre stain for from 
twenty minutes to one hour. 

5. Dehydrate in absolute alcohol. 

6. Clear in pure xylol. Balsam. 

By staining the nuclei with carmin first, and then staining the proto¬ 
plasm with orange G later, the effect of the stain will be heightened. The 
elastic fibres appear dark blue or almost black. Another stain for elastic 
fibres is that of Unna-Taenzer. 

Fat and Fatty Degeneration.—Fat is stained intensely black by osmic 
acid. Flemming's solution may be used for fixation. In preparations that 







MICROSCOPIC EXAMINATION OF THE EYE. 


787 


have been hardened in forniol, the degenerative processes may be demon¬ 
strated as follows:— 

1. Transfer the specimen from formol into Flemming’s solution. 

2. Place the sections in 6 / 10 -per-cent. strength chromic acid for three 
hours, then for twenty-four hours in 1-per-cent, strength chromic acid. 

3. Stain in hematoxylin solution and wash in a saturated solution of 
picric acid. The cell-granules are blue, while the remainder is stained 
green (Busch). 

The fat-granules within the cells have the following properties:— 

1. They do not disappear when acetic acid is added. 

2. They are resistant to the treatment with 1- to 3-per-cent, strength 
solutions of potassium and sodium hydrate. 

3. They are blackened by the addition of a 1-per-cent, strength osmic 

acid. 

4. The smallest droplets are stained intensely violet by iodin-violet. 

5. They are soluble in chloroform and ether. 

Fibrin.—Fibrin stains with the acid anilin dyes: picric acid, eosin, and 
acid fuchsin. Weigert has devised a special stain for fibrin. 

Cholesterin.—Cholesterin crystals are generally found in masses of 
fatty detritus. They are frequently found in the degenerated vitreous, in 
subchorioidal and subretinal exudations, and in the anterior chamber. 
Cholesterin is soluble in alcohol and ether; hence the crystals are not visible 
in sections that have been obtained from specimens hardened in paraffin or 
in celloidin. They leave characteristic clefts or gaps if they were present. 
When treated with Lugol’s solution (iodin, 1.0; potassium iodid, 1.0; 
water, 100.0), the crystals become dark brown. By adding a few drops of a 
30- to 40-per-cent, strength sulphuric acid they will become gradually blue- 
red, blue-green, and finally blue. 

Calcareous Degeneration.—Calcareous deposits occur in cells as well as 
in the ground-substance. The lime deposited in the tissues in the form of 
granules or clumps appears white and glittering when seen by reflected 
light; when examined by transmitted light, it appears dark. By the addi¬ 
tion of hydrochloric acid (permitted to flow in from the edge of the cover- 
glass), the calcium carbonate is dissolved, with the liberation of carbon- 
dioxid gas, while the calcium phosphate is dissolved without. By adding 
sulphuric acid gypsum crystals are formed. Lime takes a characteristic 
blue stain with alum hematoxylin; sometimes it is reddish blue. 

By Leutert’s method the slightest traces of lime can be demonstrated as 
follows:— 

1. Staining sections not imbedded in paraffin in concentrated alcoholic 
solution of hematein (for fifteen minutes). 

2. Wash in flowing water for fifteen minutes. 

3. Stain further in a 1-per-cent, strength solution of safranin (for 
from five to eight hours). 

4. Binse in water. 


788 


MODERN OPHTHALMOLOGY. 


5. Differentiate and dehydrate in alcohol, oil, and balsam. 

The lime is stained deep steel-blue and the nuclei intensely red. The 
sections are not permanent. 

Mucoid Degeneration.—There are some cells in the normal conjunctiva 
which contain mucin. In inflammatory processes of this membrane, and on 
the surface of papillomata, we find them in great numbers. If the speci¬ 
men has been stained with carmin, the mucin in the cell-body will remain 
unstained and the goblet-cells appear as light spaces in the .epithelium. 
The nucleus at the bottom of the cell only is stained red. The mucin also 
is not stained by dilute solutions of hematoxylin, hut it stains diffusely blue 
with the concentrated solutions of hematoxylin; so that the nuclei are 
difficult to discern. 

Acid fuchsin stains the mucin intensely red, safranin stains the mucin 
orange-red, and methylene blue stains the mucin blue. The following is a 
very good method:— 

1. Fix in a concentrated aqueous solution of corrosive sublimate for 
from two to eight hours. 

2. Rapidly harden and dehydrate in absolute alcohol. 

3. Imbed in celloidin or, preferably, in paraffin. 

4. Place in a concentrated aqueous solution of corrosive sublimate for 
half a minute the sections from which the paraffin has been removed. 

5. Rinse in alcohol. 

6. Stain in a dilute solution of thionin (2 drops of a saturated solu¬ 
tion of thionin to 5 cubic centimetres of water). 

7. Rinse in alcohol, 90-per-cent, strength. 

8. Rapidly dehydrate in absolute alcohol. 

9. Clear the section in a mixture of oil of cloves, 1 part, and oil of 
thyme, 5 parts. • 

10. Oil of cedar. Balsam. 

Other and more permanent stains are mucicarmin and the muci- 
hematein of P. Meyer. 

Hyalin and Colloid Degeneration.—Hyalin and colloid substances are 
characterized by their high refractive power. They are comparatively in¬ 
soluble albuminous substances which occur very frequently in the various 
structures of the eye. They are found physiologically in advanced age and 
also in chronic inflammatory processes. For fixation formol-Muller fluid 
or alcohol may be used. The substances stain well with the acid anilin dyes 
(eosin, acid fuchsin, and picric acid). With the Van Gieson stain these 
bodies are colored a brilliant red. Bismarck brown gives them a light- 
brown tint. As a nuclear stain hematoxylin may be used. 

Amyloid Degeneration.—Amyloid is very resistant to alkalies, acids, 
etc. Formol, sublimate, alcohol, and Muller’s fluid may be used to fix. 
Hematoxylin, eosin, or the Tan Gieson-Ernst stains are good. With the 
former the amyloid substance stains pink; with the latter, pink to red- 
brown. Besides these there are several specific stains, viz.:— 


MICROSCOPIC EXAMINATION OF THE EYE. 


789 


1. Iodin Reaction.— The sections are placed for from three to ten 
minutes in Lugol’s solution diluted with 3 parts of water. The sections are 
then washed and examined in glycerin. The degenerated areas are stained 
brownish red, while the unaffected tissue is yellow. The brownish-red color 
is rendered still more brilliant if 25 per cent, of glycerin is added to the solu¬ 
tion. This stain is not permanent. 

2. Iodin AND Sulphuric-Acid Reaction. —If a section has been 
treated as mentioned above, and is then placed in a 1-per-cent, strength solu¬ 
tion of sulphuric acid, the brown color will become more saturated, or be¬ 
come violet, blue, or greenish. Sometimes some of these colors can be seen 
with the iodin treatment only. 

3. Methyl-violet and Gentian-violet Reactions. —This reaction 
is not absolutely reliable, as mucus may be also stained with this method. 
The procedure is as follows:— 

1. Stain for from one-half to fifteen minutes in a 2-per-cent, strength 
solution of methyl-violet or in a gentian-violet solution. 

2. Wash in a 2-per-cent, strength solution of acetic acid or in a 1-per¬ 
cent. strength solution of hydrochloric acid for from two to three minutes. 

3. Rinse thoroughly in water. 

4. Imbed in glycerin, in a concentrated solution of potassium acetate, 
or in levulose. The cover-glass should be rimmed if the section is to be 
permanent. 

The amyloid areas become purple-red; the remainder of the tissue 
takes a blue tint. 

4. Tiiionin Stain.— 1. Stain in a concentrated aqueous solution of 
thionin for five minutes. 

2. Wash in distilled water. 

3. Dry on the slide with blotting-paper. 

4. Dehydrate and clear with anilin oil-xylol (2 to 1). 

5. Pure xylol. Canada balsam. Amyloid stains bright blue or lilac; 
the unaffected areas stain bluish or violet. 

Corpora Amylacea.—This is a local condition which manifests itself in 
foci of degeneration or amyloid concretions, having a spheric outline, and 
are fifteen to twenty-five micromillimetres in diameter. They are found in 
the prostate, the brain, the optic nerve, the chiasma, and the optic tract. 
Sometimes they are found as far back as the corpora genic-ulata externa and 
the optic thalami. The amyloid concretions are most frequently found in 
ascending atrophy after phthisis bulbi. They usually give the amyloid 
reactions with iodin and acids. When treated with Lugol’s solution, they 
appear brown or violet; the surrounding tissue is yellow. When stained 
with Lugol’s solution and treated with an acid, they become violet. When 
these concretions are found in old corneal scars, the specimen has been fixed 
in Muller’s fluid, and the section is stained with hemalum hematoxylin- 
alum-carmin, they appear yellow. In the optic nerve they stain blue with 
hematoxylin and hemalaun, and red with alum-carmin. 


790 


MODERN OPHTHALMOLOGY. 


Glycogen.—The demonstration of glycogen is of little value to the 
ophthalmologist. The method of Langhans will be mentioned here, which 
is also of value in staining amyloid, and is as follows:— 

1. Stain in Lugol’s solution (for from five to fifteen minutes). 

2. Dehydrate in a solution composed of tincture of iodin, 1.0; abso¬ 
lute alcohol, 4.0. 

3. Clear and preserve the specimen in origanum-oil by rimming the 
cover. 

THE DEMONSTRATION OF FOREIGN SUBSTANCES IN THE EYE. 

Iron.—If particles of iron remain in the eye for long periods of time 
they lead to changes known as siderosis bulbi. Von Hippel distinguishes 
two kinds of siderosis, viz.: xenogenous siderosis, due to the presence of a 
foreign body which is of iron or of steel; and hematogenous siderosis, 
following hemorrhages and due to the iron (hemosiderin) which is usually 
present in the blood. 

The two following methods are of service for the demonstration of iron 
in the eye. As a matter of course, no iron or steel teasing needles can be 
used in staining with these methods. 

Perl’s Reaction. —The eyeball should have been hardened in formol 
or alcohol. Yon Hippel claims the reaction may be obtained with specimens 
which have lain for years in Mtiller’s fluid, although it appears more slowly. 

1. Place the sections in a 2-per-cent, strength aqueous solution of 
ferrocyanid of potassium for a few minutes. 

2. Then place them in a 5 / 10 - to 1-per-cent, strength solution of hydro¬ 
chloric acid. 

3. Wash the sections in water. 

4. Clear the specimen and mount in balsam. 

If a nuclear stain is also desired, the following staining method may 
be employed:— 

1. Stain the sections in lithia-carmin for from one to two hours. 

2. Wash in water. 

3. Stain in a 2-per-cent, strength solution of ferrocyanid of potassium 
for from four to six hours. 

4. Allow the section to remain in a 1-per-cent, strength solution of 
hydrochloric acid for from six to twelve hours. 

5. Rapidly wash in water. 

6. Dehydrate in alcohol. Origanum-oil. Balsam. 

The pigment containing iron stains intensely blue. 

Quincke’s Reaction.—1. Place the sections in a freshly prepared 
solution of ammonium sulphid for from ten to twenty minutes—until they 
have acquired a dark-green color. 

2. Rinse in water. 

3. Alcohol. 

4. Oil. Balsam. 


MICROSCOPIC EXAMINATION OF THE EYE. 


791 


Should a nuclear stain be desired, the sections may be stained with 
alum carmin before or after placing the sections in ammonium sulphid. 
The iron appears in the form of dark-green granules. 

Copper.—To demonstrate the presence of copper treat the sections with 
ferrocyanid of potassium as in Perks reaction. Then place the section in 
a 1-per-cent, strength solution of acetic acid. Tissues containing copper 
will become brown-red, owing to the precipitation of ferrocyanid of copper. 

STAINING FOR BACTERIA IN SECTIONS. 

The sections should be as thin as possible in order to obtain satis¬ 
factory results. If Muller’s fluid was employed for fixation, the sections 
should be placed in a 5-per-cent, strength solution of oxalic acid for several 
hours, when a satisfactory bacterial stain may be occasionally accomplished. 
But, in all instances where bacteria are to be stained in sections, other 
fixing agents, such as absolute alcohol, formol, etc., should be used. 

(A) Methylene Blue.—1. Stain in Loffler’s alkaline methylene-blue 
for ten minutes (concentrated alcoholic methylene-blue solution, 30.0; 
potassium-hydrate solution [1 to 10,000], 100.0). 

2. Wash in water. 

3. Differentiate in Wper-cent. strength acetic acid for from one to 
three seconds. 

4 

4. Wash in water. 

5. Ninety-five-per-cent, strength alcohol. Absolute alcohol. 

6. Xylol. Balsam. 

(B) Gram-Weigert Method.—1. Stain with carmin, preferably lithia- 
carmin. 

2. Wash in water. 

3. Spread the section smoothly on the slide, on which it is to be firmly 
pressed with filter-paper. 

4. Stain for three minutes in the following, a freshly prepared solu¬ 
tion: 1 / 2 cubic centimetre of anilin-oil is emulsified with 5 cubic centi¬ 
metres of water by thoroughly shaking in a test-tube; the mixture is then 
filtered through a fine filter-paper previously moistened with water. To 
10 parts of the above solution 1 part of a filtered saturated alcoholic solu¬ 
tion of gentian-violet is added. 

5. Treat with Lugol’s solution (iodin, 1.0; potassium iodid, 2.0; 
water, 100.0) for two minutes. 

6. Dry thoroughly with filter-paper. 

7. Differentiate with anilin-xylol (2 to 1) until it is no longer tinged. 

8. Bemove the anilin-oil thoroughly with xylol. 

9. Xylol. Balsam. 





INDEX 


Abadie, 276, 525, 5S0, 584, 605 
Abducens nerve, 19 
paralysis of, 661 
radiations of, 51 
Abduction, 109, 680 
Aberration, chromatic, 69, 717 
spheric, 69, 716 
Ablepharia, 158 

Abnormal varieties of pupillary reaction, 97 
Abrasion of the cornea, 336, 355 
Abscess of the conjunctiva, -291 
of the cornea, 305, 308, 311 
of the eyelids, 162 
orbital, 630, 633 
subperiosteal, 629 

Abscission of corneal staphyloma, 356 
Absolute alcohol, 774 
glaucoma, 580 

Accessory organs of the eye, 7 
Accessory lacrimal glands, 22, 222 
examination of, 92 
Accommodation, 66 
amplitude of, 68 
explanation of, 66 
far point of, 68 
loss of, in glaucoma, 577 
measurement of, 122 
near point of, 68 
nervous mechanism of, 67 
paralysis of, 669 
paresis of, 669 
in dental irritation, 669 
range of, determination of, 121, 122 
spasm of, 697 

terms used in recording, 67, 68 
Accommodative asthenopia, 695 
Acetate of lead, 255 
Acetic acid, 262 
Acliorion Schoenleinii, 183 
Acid fuchsin, 782 

Acinotubular glands of Krause, 242 
Acne rosacea, 180 
Acoin, 302, 315 
Acromegalia, 743 
Actinomycosis, lacrimal, 224 
of conjunctiva, 291 

Actual cautery in corneal ulcers, 314, 355 
in scleral wounds, 370 
Acuity of vision, testing of, 118 
Acute ascending paralysis, 742 
contagious conjunctivitis, 252 
Adamiuk, 259 

Adams’s operation for ectropion, 208 
Addison’s disease, 361 
Adduction, 108 

Adenoid vegetations, 272, 273 
Adenoma of the chorioid, 415 
eyelids, 178 

lacrimal gland, 220, 625 
Meibomian glands, 179 
Adherent leucoma, 264, 350 
Adhesion of the iris to the cornea, 377 
Adnexa, ocular, development of, 7 
physiology of, 83 
Adrenalin chlorid, 255, 755 
Advancement operations, 684, 685 
Affections of the accessory lacrimal glands, 
222 

After-cataract. See Post-operative cataract. 
After-images, 80 
negative, 81 
positive, 80 

Age, influence of, upon glaucoma, 563 
Agraphia, 739 
Albinism, 170, 376, 412 
Albino, fundus of—Fig. 2, Plate III 


Albuminuric neuritis, 506 
neuroretinitis, 506 
retinitis, 505 
Alcohol poisoning, 544 
Alcoholic amblyopia, 544 
Aleppo boil, 161 
Alexia, cortical, 739 
subcortical, 739 
Alfieri’s method, 776 
Allantiasis, 545 
Alleman, 350 
Allport, 197 
Alopecia, 182 
areata, 182 
Alt, 23, 338, 378, 598 
Altmann, 785 
Alum carmin, 780 
Amakrine association fibres, 45 
cell, 45 

Amaurosis (see also Amblyopia) following in¬ 
fantile convulsions, 550 
from blepharospasm, 321 
from quinin, 543 
glycosuric, 552 
partialis fugax, 557 
uremic, 552 

Amaurotic cat’s eye, 484 
family idiocy, 512 
Ambidexterity, advantages of, 750 
Amblyopia, 550 
astigmatic, 550 

central (see also Retrobulbar neuritis), with 
scotoma, 555 
congenital, 550, 747 
for colors, 550 
exanopsia, 551 
from alcohol, 544 
from hemorrhage, 553 
from non-use, 551 
hysteric, 526, 558 
malarial, 559, 747 
of nervous origin, 745 
pretended, 556 
reflex, 558, 747 
simulated, 151, 556, 747 
toxic, 542 
Amblyoscope, 674 
Amboyna button, 161 
Ametropia, 692 
axial, 692 
medial, 692 
meridional, 692 
Ammann, 513 

Ammonia causing conjunctivitis, 269 
Amnesia, visual, 739 
Amnesic color-blindness, 739 
Amplitude of accommodation, 68 
Amyloid degeneration, demonstration of, 788 
of the conjunctiva, 287 
Anagnostakis, 205 
Anaphoria, 670 

Anatomic changes in glaucomatous eyes, 567 
position of rest, 73 
Anatomy, 8-61 
of the capsule of Tenon, 11 
cervical ganglia, 19 
sympathetic, 19 
check ligaments, 15 
chiasma, 47 
chorioid, 38 
ciliary body, 36 
ganglion, 17 
glands, 38 
muscle, 37 
processes, 37 
conjunctiva, 27 


(793) 







INDEX. 


794 


Anatomy of the cornea, 29 
corneoscleral junction, 40 
crystalline lens, 51 
eye, 8-61 
eyeball, 29 
eyelids, 24 

fovea centralis, 42, 46 
fundus oculi, 56 
interorbital space, 11 
iridocorneal angle, 41 
iris, 33 

lacrimal apparatus, 22 
glands, 22 

ligamentum pectinatum, 40 
macula lutea, 46 
motor oculi nerve, 17, 50 
nasal duct, 24 
ocular lymph-spaces, 55 
muscles, 12 
nerves, 17 

oculomotor nerve, 17, 50 
ophthalmic artery, 20 
nerve, 18 
vein, 21 

optic commissure, 47 
disc, 57 

nerve, 5, 41, 49 
orbit, 8 

orbital muscles, 12 
patheticus nerve, 18, 51 
retina, 5, 42 

retinal blood-vessels, 58 
sclera, 32 

secondary eye-cup, 4 
vitreous body, or humor, 3, 54 
zonula of Zinn, 5, 54 
Andrade, 310 
Andrew, 295 
Andrews, 380 
Anel, 233 
Anemia, 509 

Anesthesia, general, 754 
infiltration, 754 
local, 754 

of cornea, 316, 567, 576, 577 
of retina, 526 
Anesthetics, general, 754 
local, 754 

Aneurism, aortic, 97 
of orbit, 101 
of retinal vessels, 492 
Angioid streaks in the retina, 518 
Angioma cavernosum, 175 
cavernous, of conjunctiva, 242 
of eyelids, 175 
of orbit, 621 
Angle alpha, 69, 698 

in hypermetropia, 698 
beta, 69 
gamma, 69 
in myopia, 713 
in strabismus, 113 
negative, 113 
positive, 113 

metre. See Metre angle. 
of deviation, 687 
of incidence, 687 
of squint, determination of, 672 
refracting, 688 
the visual, 65, 119 
Aniridia, 376 

Anisocoria. See Inequality of pupils. 
Anisometropia, 730 
Ankyloblepharon, 159, 190, 295 
Annular conus, 711 
posterior synechia, 387 
staphyloma, 425 
Anomalies of the chorioid, 411 
ciliary body, 404 
conjunctiva, 239 
cornea, 303 
crystalline lens, 437 
eyeball, 617 
eyelids, 158 
iris, 374 

lacrimal apparatus, 222, 223 

optic nerve, 528 

orbit, 616 

retina, 481 

sclera, 361 


Anomalies of the vitreous humor, 473 
Anophthalmos, 528, 617 

Anterior chamber, angle of, anatomy of, 41 
in glaucoma, 568 
anomalies of, 396 
cilia in, 396 

changes of depth of, 396 
of contents of, 396 
foreign bodies in, 396 
parasites in, 396 
Anterior chorioiditis, 422, 426 
Anterior polar cataract, 264, 308, 444 
Anterior sclerotomy, 591 
symblepharon, 293 
synechia, 264, 309 
Anteversion of the iris, 394 
Anthrax, 162 
Antimetropia, 730 
Antonelli, 222 
Antrum of Highmore, 228 
diseases of, 633 
Aortic insufficiency, 573 
Aphakia, 439, 724 
congenital, 438 
glasses in, 725 
iridectomy in, 400, 585 
Aplasia of optic nerve, 528 
Apoplexy of optic nerve, 549 
Aqueduct of Fallopius, 188 
of Sylvius, 67, 71, 97, 741 
Aqueous humor, 562 
composition of, in glaucoma, 562 
Aquocapsulitis, 406 
Arch, external tarsal, 28 
tarsal, 28 
Arcus senilis, 349 
Arecolin, 134, 366, 576 
Areolar chorioiditis, 423 
Argamblyopia, 551 
Argentamin, 251 

Argyll Robertson pupils, 97, 545, 741 
Argyria, 167 

Argyrol, 251, 255, 257, 259, 283 
Argyrosis, 290 
Aristol, 270, 290, 337 

Arlt, 202, 206, 254, 260, 29S. 379, 500, 607, 632 
method of enucleation, 607, 608, 609 
Arnold, 603 
illustrations from, 52, 53 
Arteria centralis retinas, 6, 21 
embolism of, 494 
Arterial circle of iris, large, 34 
small, 34 

Arterial pulsation, 58 
in glaucoma, 569, 573, 576 
Arteriosclerosis, 490, 492, 493, 510, 511 
Artery, anterior ethmoidal, 2i 
central retinal, 21 
frontal, 21 
hyaloid, 4. 473 
lacrimal, 20 
long ciliary, 20 
muscular, 21 
nasal, 21 
ophthalmic, 20 
palpebral, 28 
posterior ciliary, 20 
supra-orbital, 28 
Artificial eyes, 614 
Artificial ripening of cataract, 466 
Aseptic flask, 247 
Ashby, 550 

Aspergillar keratitis, 330 
Aspergillus fumigatus, 330 
glaucus, 330 
Aspirin, 366 

Associated movements, 74 
Asteatosis, 180 
Asteroid hyalitis, 475 
Asthenopia, 745 
accommodative, 695 
muscular, 679 
neurasthenic, 526 
Astigmatic chart, 722 
eye, appearance of vessels in, 142 
form of image, 718 
Astigmatism, 70, 692, 716 
against the rule, 718 
irregular. 723 
regular, 717 



INDEX. 


795 


Astigmatism with the rule, 718 
Astigmometer, 116 
Astigmometry, 115 
Ataxia, ocular, 740, 741 
paraplegia, 742 

Atheromatous ulcer of the cornea, 311 
Atrabilin, 755 

Atresia of the canaliculi, 223 
of the pupil, congenital, 3 
Atropa belladonna, 132 
Atrophia bulbi, 488 
Atrophy of conjunctiva, 288 
of eyeball, 409, 422, 434, 436 
of lacrimal gland, 220 
of limbus, 340 
of optic nerve, 528, 545 
of retina, 503 
Atropin, 132, 255, 266 
conjunctivitis, 259 
Aura, visual, 740 
Autograft, 216 
Avulsion of eyeball, 647 
Axenfeld, 256, 312, 429, 509 
Axis, optic, 62, 68 
Axonometer, 150 
Ayres, 222 


Baas, 222 

Bacillus of diphtheria, 271 
Klebs-Loeffler, 269. 271 
Koch-Weeks, 252, 253, 256 
of Hoffmann, 271 
tubercle, 172, 181, 289 
xerosis, 271, 288 

Back-water theory of papillitis, 536 
Bacteria, staining for, 791 
Baer, 669 

Bacterium coli commune, 263 
Baker. A. R., illustration from—Fig. 2, Plate 
XVIII 

Balance of the ocular muscles, 101 

Bandages, 754 

Baquis, 638 

Barck, 359, 647 

Basal lesions, 667 

Basedow’s disease, 641, 745 

Bates, 92, 448 

Baumgarten, 365 

Beck, 338 

Becker, 559, 598, 645, 777 
Beer, 221, 356, 460, 484, 641 
Bellarminoff, 417 
Bell’s palsy, 668 
Benedikt, 537 
BENSON, 94, 475, 496, 559 
Berger, 644, 741 
Bergmeister. 583 
Berlin, 281, 603, 649 
Bernays, 208 
Berry, 356, 475, 619 
Berzelius, 442 
Bettman, 467 
Bettremieux. 232 
BlCKERTON, 128, 613 
BlETTI, 263 
Billroth, 621 
Binocular field of vision, 77 
movements, 656 
single vision, 75 
vision, testing of, 151 
Binoculus, 754 
Birch-Hirschfeld, 543 
Birnbacher, 199 

Bjerrum’s method of perimetry, 125 
Black, 295 

Black cataract, 448, 449 
“Black eye,’’ 193, 194, 646 
Blasius’S blepharoplasty, 214 
Blastomycetic dermatitis, 166 
Bled, 584 

Blennorrhea of the lacrimal sac, 224 
Blepharitis acarica, 186 
ciliaris, 185 
diagnosis of, 186 
eczematosa, 185, 187 
etiology of, 186 
hypertrophic, 186 
marginalis. 185 
pediculosa, 182 


Blepharitis, prognosis of, 186 
squamosa, 185 
treatment of, 186 
trichophytica, 186 
ulcerosa, 185 
Blepharoadenitis, 185 
Blepharochalasis, 184 
Blepharophimosis, 188 
congenital, 159 

Blepharoplasty, methods of, 213 
Blepharoptosis, 191 
Blepharospasm, 189 
Blepharotomy, 200 
Blind spot, 78 

Blindness, binocular, feigned, 151, 556 
during ocular movements, 75 
feigned, 556 
hysteric, 558 

Blood in anterior chamber, 396 
-staining of the cornea, 339 
Blue vision, 559 
Bluestone, 259 
Bock, 262 

Boeckmann, 284, 301 

Bohm, illustrations from, 30, 31, 36, 37. 40, 59 
Boil, Aleppo, 161 
Delhi, 161 

Boll’s retinal purple, 80 

Bonnet’s method of enucleation, 607, 608 

Borax-carmin, 7S0 

Boric acid, 284 

Borsch, 555 

Botulism, 545 

Boucheron, 561 

Bowman’s layer of the cornea, 30, 246 
probe, 235 
Brachet, 300 
Brady, 223 
Brain, abscess of, 535 
tumor of, 508 
Bramwell, 508 
Brettauer, 468 
“Bridge coloboma,” 374 
Bright’s retinitis, 505 
Broca’s lobe, 739 
Broekaert, 207 
Bronner, 175, 437, 594 
Brassage, 262, 283 
Brown-Sf.quard, 537 
Brucke, 38 
Bruns, 643 
Bryant, 612 
Buchanan, 557 
Buckley, 292 
Bulbar paralysis, 742 

Bull, C. S., 380, 388, 427, 429, 430, 511, 576, 630, 
633 

Bullae of conjunctiva, 275 
of cornea, 329 
of eyelids, 165 
Buller, 222, 280 
Buller’s shield, 265, 270, 272 
Bullous keratitis, 329 
Buphthalmos, 582 
Burchardt, 121 
Burnett, S. M., 242, 281, 364 
Butler, 642 
Buxton, 128 
Byers, 222, 530, 531 

Calcareous cataract, 445 
degeneration, demonstration of, 787 
keratitis, 334 

Caldwell’S lacrimal probes. 236 
operation on obliterated nasal canal, 237 
Callan, 382, 466 
Calmette’s serum, 174 
Calomel, 274, 371 
Campimeter, 124 
Canal for the nasal duct, 10 
hyaloid, 4, 56 
of Cloquet, 54, 473 
of Schlemm, 41 
rupture of, 369 
Canaliculi, anomalies of, 223 
Canaliculus, actinomycosis of, 224 
foreign bodies in, 223 
leptothrix in, 223 
mucocele of the lower, 223 
polyp of, 223 




796 


INDEX. 


Canaliculus, slitting of, 234 
streptothrix of, 224 
wound of, 193 
Cancroid ulcer, 177 
Canites, 601, 743 

Cannabis Indica, amblyopia from, 542 
Canthoplasty, 200 

Canthotomy (see also Blepharotomy ), 161, 162, 
189 

Capsular advancement, 685 
cataract, 446 
Capsule of Bonnet, 11 
of Tenon, 11 
advancement of, 685 
inflammation of, 632 
Capsulo-pupillary membrane, 466 
Capsulotomy, 452, 460 
immediate, 460 
Carbol-fucbsin. 256 
Carbolic acid in corneal ulcers, 314 
Carbon bisulphid, amblyopia from, 542 
Carbuncle, 162 
Carcinoma of caruncle, 296 
of chorioid, 414 
of ciliary body, 405 
of conjunctiva, 246 
of eyelid, 176 
of lacrimal gland, 221 
of orbit, 621, 625 
Cardinal points, 63 

Care of the eyes during school-life, 762 
Caries of orbit, 535, 627 
Carpenter, 388, 413 
Carron-oil, 194 
Carter, 357 
Caruncle, abscess of, 296 
affections of, 295 
anatomy of, 25 
carcinoma of, 296 
cylindroma of, 296 
dermoid of, 296 
fibroma of, 296 
lithiasis of, 296 
lymphangioma of, 296 
sarcoma of, 296 

sinking of, after tenotomy, 683 
trichosis of, 296 
tumors of, 296 
Case history, 85 
Caspar, 518 
Cassaripe, 316 
Cataphoria, 670 
Cataract, 439 
accrete, 448 

anterior polar, 264, 308, 444 
artificial ripening of, 466 
axial, 443 
black, 448 
calcareous, 445 
capsular, 439, 446, 447 
central, 444 
complete, 443 
complicated, 448 
congenital, 443 
coralliform, 444 
course of, 442 
delivery of, 453 
diabetic, 449 
diagnosis of, 441 
etiology of, 442 
extraction of, 451 
in its capsule, 459 
linear, 460 
of immature, 461 
with iridectomy, 453 
with Kalt suture, 459 
without iridectomy, 451 
without speculum, 461 
glaucomatous, 568 
gray, 439 

immature, extraction of, 461 

immediate capsulotomy in extraction, 460 

incipient, 441 

incomplete, 443 

juvenile, 444, 463 

lactate, 445 

membranous, 445 

milky, 445 

Morgagnian, 442 

operations for, 449 


Cataract, operations for, choice of, 458 
results of, 468 
osseous, 445 
pathology of, 442 
posterior polar, 444 
post-operative, 446, 465 
prognosis of, 443 
punctate, 444 
secondary, 448 
senile, 439 
simple, 439 
soft, 444 

spontaneous cure of, 468 
spontaneous delivery of, 453 
stellar, 444 

traumatic, 445, 446, 464 
treatment of, 443, 444, 445, 446 
zonular, 444 
Catarrh, follicular, 257 
of lacrimal sac, 225 
Catarrhal ulcer, 253 
Caterpillar-hairs, 285 
Catoptric images, 67 
test, 441 

Cautery. See Actual cautery. 

Cavernous sinus, compression of, 536 
thrombosis of, 636 
Celloidin imbedding, 777 
Cellulitis of orbit, 630 
Centrad, 688 

Centre of rotation, 68, 72 
visual, 82 

Cerebellum, tumors, of, 534 
Cerebral layer of the retina, 44 
Cerebritis, 535 

Cerebrospinal meningitis, 740 
Chabaneix, 230 
Chalazion, diagnosis of, 182 
etiology of, 182 
external, 181 
internal, 181 
operations for, 195 
pathology of, 181 
symptoms of, 181 
treatment of, 182 
Chalk’s eye-drop bottle, 247 
Chamber, anterior. See Anterior chamber. 

posterior. See Posterior chamber. 

Chance, 276 
Chandler, 316 

Charcot, ophthalmic migraine of, 191 
Chartres, 264 
Chauffard, 584 
Chaulmoogra-oil, 174 
Cheatham, 284 

Chemosis, 253, 256, 263, 266, 276, 293, 631, 632 
Cherry-red spot in macula, 495 
Cheselden, 400 
Chiasma, optic, 47 
Chloasma, 167 

Chlorin-water, intra-ocular injections of, 475 
Chloroform, 754 
Chloroma, 222 
Chlorosis, 535 
Choked disc, 533, 534, 535 
Cholesteatoma of iris, 378 
Cholesterin, demonstration of, 787 
Chondroma of lacrimal gland, 222 
Chorea, 496, 744 
Chorioid, adenoma of, 415 
albinism of, 412 
anatomy of, 38 
angiosarcoma of, 415 
carcinoma of, 414 

central senile areolar atrophy of, 424 

chronic inflammatory processes in, 4S6 

colloid changes in, 435 

coloboma of, 411 

congenital anomalies of, 411 

congestion of, 420 

cysts of, 414 

detachment of, 417, 434 

diseases of, 411-436 

enchondroma of, 415 

foreign bodies in, 433 

gumma of, 419 

hemorrhage into, 433 

hyperemia of, 420 

inflammation of, 420 

injuries of, 433 



INDEX. 


797 


Chorioid, large tubercular mass in, 413 
leucosarcoma of, 486 
leucosis of, 412 
macular coloboma of, 412 
myoma of, 420 
nevi of, 420 
ossification of, 420 
perithelioma of, 415 
rupture of, 434 
sarcoma of, 415 
diagnosis, 416 
metastatic, 415 
pathology, 419 
prognosis, 419 
symptoms, 416 
treatment, 419 
sclerosis of vessels of, 424 
senile areolar atrophy of, 424 
solitary tubercle of, 418 
telangiectatic sarcoma of, 415 
tuberculosis of, 412, 486 
tumors of, 414 
wounds of, 433 
Chorioidal craters, 522 
hemorrhage, 433 
Chorioiditis, 420 
acute, 421 
anterior, 422, 426 
areolar, 423 
atrophic, 421 
causes of, 427 
central, 422, 423 
“central senile guttate,” 424 
character of pigment in, 421, 428 
clinical forms of, 422 
diagnosis of, 427 
diffuse syphilitic, 501 
disseminated, 422, 423 
exudative, non-suppurative, 420 
from errors of refraction, 427 
gonorrheal, 422, 427 
guttate, 424 
hereditary, 427 
metastatic, 429 
myopic, 422, 425 
old, 428 

pathology of, 427 
plastic, 420 
prognosis of, 428 
purulent, 429 
recent, 428 
serous, 420 
suppurative, 429 
symrttoms of, 421 

syphilitic, 422, 426. See Syphilitic retinitis. 
Tay’s, 424, 516 
treatment of, 428 
with descemetitis, 422, 426 
Chorioidoretinitis, 420, 559 
striata, 518 
sympathetic, 600 
synhilitic, 426, 501, 504, 559 
Chromatic aberration, 69, 717 
Chromidrosis, 179 

Chronic catarrhal conjunctivitis, 256 
Chronic conjunctivitis, 277 
Cicatricial orbit, operations for, 615 
pterygium, 287 
Cilia. See Eyelashes. 

Ciliary body, anatomy of, 36 
angiomata of, 405 
calcification of, 405 
carcinomata of, 405 
coloboma of, 404 
cysts of, 405 
diseases of, 404 
fibromyomata of, 405 
foreign bodies in, 409 
gumma of, 405 
inflammation of, 406 
plastic, 408 
purulent, 409 
injuries of, 409 
myomata of, 405 
ossification of, 405 
sarcomata of, 405 
tuberculosis of, 405 
tumors of. 404 
wounds of, 409 
congestion, 248 


Ciliary ganglion, 17 
glands, 38, 407 
iniection, 248 
muscle, 37 

part of the retina, 46 
processes, 37 
ring, 36 

staphyloma, 366 
vessels, anterior, 91, 248, 580 
Cilioretinal artery, 59 
vein, 59 

vessels in embolism, 496 
Cinchona, amblyopia from, 543 
Cinnamate of sodium, 302 
ClRINCIONE, 225, 532 
Citrate of copper, 283 
Clearness of vision, SI 

Climatic changes in their effect on the eyes, 
770 

Cloquet, canal of, 54, 473, 478 
Cnidosis, 160 
Cobalt-glass test, 677 
Cocain, 255, 451, 754 
Coe, 297 

Coffee, amblyopia from, 542 
Cohn, 553, 707 
COHNHEIM, 740 

Collins, Treacher, 51, 156 , 305, 339 , 310, 
374, 407, 437, 458, 496, 578, 583 
Collins, W. J., 442 
Colloid bodies in nerve-head, 532 
degeneration of the skin, 179 
dis’ease of the macular region, 435 
Collyrium, application of, 250 
Coloboma, macular, 412 
of chorioid and retina, 411 
of cornea, 304 
of eyelid, 158 
of iris, 374 
of lens, 437 
of retina, 411, 481 
of sheath of optic nerve, 528 
of vitreous humor, 473 
Colon bacillus, 263, 269 
Color-field of vision, 78 
reversal of, 558 

Color-perception, theories of, 83, 550 
variation of normal, 83 
Color-sense, testing of, 127 
Comitant convergent squint, 671 
divergent strabismus, 671 
Commotio retinas, 521 
Concave lens, definition of, 688 
retinoscopy mirror, 147 
Concussion of the retina, 521 
Congenital cataract, 443 
cupping of the optic disc, 529 
hyperkeratosis, 167 
iritis, 388 

luxation of the lens, 439 
paralysis, 733 
ptosis, 159, 191, 196 

Congestion of posterior conjunctival vessels, 
248 

Conic cornea, 344 
operative treatment of, 355 
optic treatment of, 345 
Conium, 190 
Conjugate foci, 689 
lateral deviation, 744 
paralysis, 733 

Conjunctiva, abscess of, 291 
actinomycosis of, 291 
acute blennorrhea of, 262 
amyloid degeneration of, 2S7 
anatomy of, 27 
angioma of, 242 
argyrosis of, 290 
atrophy of, 288 
blood-vessels of, 90, 248 
burns of, 294 
calcification of. 284 
carcinoma of, 246 
cavernous angioma of, 242 
chancre of, 291, 292; Fig. 7, Plate VII 
chemosis of, 293 
congenital anomalies of, 239 
copper-colored spots in, 292 
cylindroma of, 246 
cysticercus of, 243 



798 


INDEX. 


Conjunctiva, cysts of, 242 
dermoid tumors of, 240 
diseases of, 239-302 
dry catarrh of, 248 
ecchymosis of, 293 
edema of, 253 
emphysema of, 293 
epibulbar sarcoma of, 244 
epithelioma of, 245, 246 
essential shrinking of, 165, 193, 275 
examination of, 89 
fibroma of, 240 
fibro-osteomata of, 242 
folliculosis of, 257 
foreign bodies in, 294 
granulation tumors of, 241 
grattage of, 301 
gumma of, 292 
hemorrhage beneath, 293 
hemorrhage from, 291 
herpes of, 274 
hyperemia of, 248 
symptoms, 249 
treatment, 249 
inflammations of, 247 
injuries to, 294 
leprosy of, 290 
leucosarcoma of, 244 
lime-burns of, 294 
lipoma of, 240 
lithiasis of, 276 
lupus of, 291 
lymphangieetasis of, 243 
lymphoma of, 275 
melanosarcoma of, 244 
mucous patches of, 292 
myxoma of, 241 

necrosis of, after injections, 302 

operations on, 296 

osteoma of, 242 

papillomata of, 241 

pemphigus of, 275 

phlebolith of, 242 

pigmentation of, in trachoma, 280 

polypi of, 241 

sarcoma of, 244 

scalds of, 294 

siderosis of, 290 

spring catarrh of, 260 

symblepharon of, 293 

syphilis of, 291 

telangiectases of, 171 

tuberculosis of, 289 

tumors of, 239 

ulcers of, 292 

vaccinia of, 284 

varicella of, 284 

vascular tumors of, 242 

wounds of, 295 

xerosis of, 288 

Conjunctival injection, 247, 248 
sac, anatomy of, 25 
temperature of, 239 
vessels, anterior, 91 
posterior, 90 
Conjunctivitides, 250 
Conjunctivitis, 247 
acute contagious, 252 
clinical varieties of, 254 
diagnosis of, 253 
etiology of, 252 
pathology of, 252 
prognosis of, 254 
symptoms of, 253 
treatment of, 254 
atropin, 259 
catarrhal, 251 
caterpillar-hair, 285 
chronic, 277 
catarrhal, 256 
etiology, 257 
treatment, 257 
croupous, 269 
diagnosis, 270 
etiology, 269 
symptoms, 270 
treatment, 270 
diphtheritic, 271 
diagnosis, 271 
etiology, 271 


Conjunctivitis, diphtheritic, symptoms, 271 
treatment, 272 
diplobacillus, 256 
eczematosa, 272 
Egyptian, 277 
exanthematous, 254 
follicular, 254, 257 
diagnosis, 258 
etiology, 258 
symptoms, 258 
treatment, 258 
from electric light, 254 
from x-rays, 254 
gonorrheal, 262 
of the adult, 263 
complications, 264 
diagnosis, 264 
etiology, 264 
prognosis, 265 
prophylaxis, 265 
symptoms, 263 
treatment, 265 
of the newborn, 267 
diagnosis, 267 
etiology, 267 
prognosis, 267 
prophylaxis, 267 
symptoms, 267 
treatment, 268 
granular, 277 
complications, 280 
diagnosis, 281 
etiology, 277 • 

forms, 278 
pathology, 281 
prognosis, 282 
treatment, 282 
Ivoch-Weeks bacillus, 252 
lacrimal, 277 
membranous, 269 
metastatic gonorrheal, 254 
military, 277 
muco-purulent, 252 

neonatorum. See Conjunctivitis, gonorrheal. 
papular, 275 
Parinaud’s. 275 
petrificans, 284 
phlyctenular, 272 
diagnosis, 273 
etiology, 272 
prognosis, 273 
symptoms, 273 
treatment, 274 
plastic, 269 
pneumococcic, 256 
pseudomembranous, 269 
purulent gonorrheal, 262 
non-gonorrheal, 268 
treatment, 269' 
pustular, 254 
simple, 251 
spring, 260 
diagnosis, 260 
etiology, 260 
pathology, 261 
prognosis, 261 
symptoms, 260 
treatment, 261 
subacute catarrhal, 256 
toxic, 259 
traumatic, 254 
uratic, 276 
variolar, 276 
vernal, 260 

Construction of school-buildings, 763 
Contraction of the pupil, 71 
Conus, 367, 425, 528, 710 
Convergence, amplitude of, 124 
and accommodation, 123 
excess in esophoria, 679 
excessive, 679 
far point of, 123 
insufficiency of. 679 
measurement of, 123 
near point of, 123. 678 
negative, 123 
positive, 124 

power of, how measured, 678 

reflex of pupil. See Robertson symptom. 

test of, 124 




INDEX. 


799 


Convex lens, virtual image of, 64 
Coover, 295 

Copper, demonstration of, 791 
Coppez, 269, 271, 312 
Corectopia, 375 
Corelysis, 393, 397 
Cornea, abrasion of the, 355 
abscess of, 305, 308, 311 
anatomy of, 29 
anterior elastic lamina of, 30 
atheromatous ulcer of, 311 
atrophy of limbus of, 340 
blood-staining of, 339 
blood-vessels of, 31 

in disease, 306 
Bowman’s layer of, 30 
canaliculi of, 30 

causes of infective ulcers of, 309 
cauterization of, 355 
cells of, 30 

changes in, in exophthalmic goitre, 644 
classification of inflammations of, 307 
collapse of, 453 
congenital anomalies of, 303 
conic, 344 
corpuscles of, 30 
creeping ulcer of, 311 
crescentic ulcer of, 311 
, cyst of, 305 
dendritic ulcer of, 311, 331 
dermoid of, 304 
diameter of, normal, 29 
discoloration of, with blood-pigment, 339 
diseases of, 303-360 
ectasia of, congenital, 304 
eczema of, 320 
edema of, in glaucoma, 567 
endothelium of, 31 
epithelioma of, 305 
examination of, 92, 93 
excision of, 356 
exhaustion ulcer of, 318 
fibrillse of, 30 
fibroma of, 305 
fistula of, 346 

fistulous staphyloma of, 346 
foreign bodies in, 354 
fungus infection of, 309, 330 
globosa, 345 

healing of wounds of, 353 
hemorrhage into, 353 
herpes of, 336 

after cataract extraction, 456 
horizontal meridian of, 29 
infantile ulceration of, with xerosis of con¬ 
junctiva, 318 
injuries of, 351 
inspection of, 92 
keloid of, 305 
keratocele, 308, 346 
lepra of, 341 

mechanical injuries of, 352 
onyx, 307 
opacities of, 349 
operations on, 355 
paracentesis of, 355 
pemphigus of, 329 
perforation of, 308, 314, 315 
posterior elastic lamina of, 31 
protrusions of, 341 
relapsing herpes of, 333 
ribbon-shaped opacity of, 334 
ring ulcer of, 310 
rodent ulcer of, 310 
round central ulcer of, 31C 
Saemisch’s incision of, 315, 357 
sclerosis of limbus of, 340 
subepithelial opacity of, 335 
siderosis of, 341 
staphyloma of, 341 
tattooing of, 359 
tonsure of, 301 
transverse film of, 334 
tuberculosis of, 341 
xanthelasma of, 341 
zonular opacity of, 334 
Corneal ulcers in trachoma, 280 
wounds, healing of, 353 
Corneitis. See Keratitis. 

Cornu cutaneum, 168 


Cornwall, 349 

Corpora amylacea, demonstration of, 789 
geniculata, 41 
quadrigemina, 41 

Corresponding points of the retina, 75 
Cortical reflex of Haab, 98 
“Couching” of cataract, 462 
Cover test for heterophoria, 677 
Crede’s method. 268 
Creeping ulcer of the cornea, 311 
Creolin, 260 
“Crick’s” dots, 515 
Critchett, 242, 343, 531, 605 
operation for staphyloma of cornea, 356 
Croupous conjunctivitis, 269 
Cryptophthalmos, 158 
Crystalline lens, absence of, 439 
anatomy of, 51 
calcification of, 445 
capsule of, 54 

changes in, in accommodation, 66 
coloboma of, 437 
congenital anomalies of, 437 
congenital luxation of, 439 
dimensions of, 51 
diseases of, 437-472 
dislocation of, 439, 469 
examination of, 98 
fetal, 3 

foreign bodies in, 472 
growth of, 51 
increase in size of, 51 
injuries of, 471 
luxation of, 439, 469 
opacity of, 439 
operations upon, 449 
ossification of, 471 
parasites in, 471 
regeneration of, 471 
removal of, in myopia, 716 
spontaneous delivery of, 453 
spontaneous extrusion of, 471 
structure of, 52 
suspensory ligament of, 54 
swelling of, 440, 464 
Cuneus, 41 
Cuprol, 255 
Curettement. 162 
Cutting of sections, 779 
the eyeball, 777 
I Cyanopsia, 559 
I Cyanuret of mercury, 302 
Cyclicotomy, 590 
Cyclitis, 406, 408 
after cataract extraction, 456 
pathologv. 407, 409 
plastic, 408 
prognosis of, 407 
purulent, 409 
serous, 406 
symptoms of. 407, 408 
traumatic, 409 
treatment of, 407, 409 
varieties, 406 
Cyclophoria, 101 
test for, 677 
Cyclopia, 616 
Cycloplegia, 131, 669 
Cycloplegics, 132 
Cylindric lenses, 690 
Cylindroma of conjunctiva, 246 
Cyst, dermoid, of conjunctiva. 240 
gelatinous of conjunctiva, 243 
of chorioid, 414 
of cornea, 305 
of eyelid. 167 
of iris, 377 
of orbit, 618, 625 
of retina, 482 
of sclera, 361 
sebaceous, of eyelid, 180 
subconjunctival, 242 
Cysticerci of conjunctiva, 243 
of eyelids, 183 
of iris, 381 
of retina, 488 
of vitreous humor, 478 
Cysticercus, intra-ocular, 418 
Cystoid cicatrix, after cataract extraction, 457 
Cystotomy, 452, 462 







800 


INDEX. 


Czermak, 192, 357, 606 

Dacryoadenalgia, 220 
Dacryoadenitis, acute, 219 
chronic, 220 

Dacryocystitis, catarrhal, 225 
suppurative, 226 
Bacryolith, 220 
Dacryops, 221 
Dactylitis, 272 
Dalrymple’s sign, 87, 644 
Daltonism, 550 
Danvers, 246, 261, 262 
Darier, 262, 315, 321, 339, 362, 363, 391 
Darier’s disease, 172 
Davidson, 154, 651 
Davis, A. E., 114 
Day-blindness, 557 
De Beck, 173, 351, 375, 395 
De Lapersonne, 433 

De Schweinitz, 260, 415, 435, 487. 519, 639, 640 
De WECKER. 284, 343, 349, 357, 359, 400, 401, 
403, 513, 592 

operation for staphyloma, 357 
scissors of, 399 

in secondary cataract operations, 466 
Decaleification of eye specimens, 775 
Defects in the visual field. 126 
Dehydration of sections, 784 
Dejerine, 739 

Delafield’s hematoxylin, 780 
Delhi boil, 161 

Delirium after cataract extraction, 454 
Demicheri, 291 
Demodex folliculorum, 186 
Demours, membrane of, 31 
Dendritic keratitis, 331 
Dendritic ulcer of the cornea, 311, 331 
Denig, 638 

Dennett’s method of measuring prisms, 68S 
DfiPOUTOL, 647 
Depression of cataract, 462 
Depth, sense of, 76 
Derby, 179, 54S, 707 
Dermatitis, 165, 457 
blastomycetic, 166 
herpetiformis, 165 
medicamentosa, 165 
venenata, 165 

Dermoid cyst of eyelid, 167 
of orbit, 618, 619 
of caruncle, 296 
of conjunctiva, 239, 240 
of cornea, 304 
Dermolipomata, 240 
Descemet, membrane of, 31 
Descemetitis, 333, 406 
Descending neuritis, 534 
Deschamps, 400 
iridectomy in aphakic eyes, 400 
Desmarres, 202, 230, 392 
depletion, 392 
Despagnet, 275, 300 
Detachment of chorioid, 417 
of retina, 416, 522 
etiology of, 522 
in myopia, 710 
pathology of, 523 
prognosis of, 524 
symptoms of, 523 
treatment of, 524 
of vitreous, 480, 710 
Deutschmann, 594, 600 
Development of the eye, 1 
Diabetic cataract, 449 
coma, 449 
iritis, 389 
retinitis, 503 
Diameter of cornea, 29 
of pupil, 71 
Dichromasia, 550 

Dieffenbach’s operation for ectropion, 208 

Diffuse dots in the retina, 516 

Dilation of the pupil, 71 

Dilator pupillae, 34 

Diminishing hypermetropia, 692 

Dimmer, 436, 493 

Dionin, 321, 391, 392 

Dioptre, the, 688 

Dioptric apparatus, 62 


Diphtheria antitoxin, 179, 270. 272 
Diphtheritic conjunctivitis, 271 
Diplobacillus conjunctivitis. 256 
of Morax and Axenfeld, 256 
Diplococcus intracellularis meningitidis, 269 
Diplopia, 72, 661, 662, 663 
crossed, 663 
horizontal, 661 
in the lower field, 662 
in the upper field, 662 
monocular, 72 

turning of head to avoid, 659 
vertical, 662 

Direct method of ophthalmoscopy, 136, 137 
Direct vision, 79 
Disc, optic, 57 

Discission of cataract, 448, 463 
glaucoma after, 448 
of post-operative cataract, 465 
Disc-like keratitis, 339 
Dislocation of eyeball, 647 
of lacrimal gland, 221 
of lens, acquired, 469 
diagnosis of, 469 
prognosis of, 470 
treatment of, 470 
congenital, 439 
intentional, 462 
Disseminated sclerosis, 740 
Distichiasis, 190 
congenital, 159 
Divergence excess, 679 
insufficiency, 679 
Dixon, 43 

Dobell’s solution, 228 
Dock, 222 
Dodd, 504, 559 
Dodge, 75 
Dojer, 72 
Dominique. 275 
Donders, 58, 72, 562, 726 
DOR, 525 

Double vision. See Diplopia. 

Douglass, 185 
Doyne, 437 
Dransart, 199 
Dressings, preparation of, 753 
Dropping of fluid from the nostril, 541 
Druault, 312 
Drug conjunctivitis, 259 
Drusenbildungen in optic papilla, 532 
Duane, 663, 664, 676, 678 
Duboisin, 133 
Duchenne’s disease, 188 
Duct, lacrimo-nasal, 24 
obstruction of, 227 
probing of, 235 
stricture of, 227 
Dudley, 559 
Dunn, 439. 463 

Duration of visual sensations, 80 
Dyer, I., 174 

Dyschromatopsia. See Dichromasia. 
Dyslexia, 739 

Ear disease, 637 
Ecchymosis of conjunctiva, 293 
of eyelids, 193 
subconjunctival, 293 
Echinococcus in orbit, 626 
subretinal. 489 
Ectasia of cornea, 304 
sclerae, 366 
Ectoderm, 2 

Ectogenous panophthalmitis, 430 
Ectopia lentis, 439 
Ectropion, 192, 223 
acute, 207 
cicatricial, 192 
congenital, 159 
of uvea, 376 
operations for, 207 
organic, 280 
spastic, 280 
treatment of, 192 
varieties of, 192 
Eczema, 160 
neurotic, 160 
of conjunctiva, 272 
of cornea, 320 



INDEX. 


801 


Eczema of eyelids, 160 
of nose and lip, 273 
seborrheic, 160 
strumous, 160 
Edema of conjunctiva, 253 
of cornea, 567 
of eyelids, 168, 169 

Edematous swelling of the retina, 521 

Edmunds, 538, 553 

Edsall, 546 

Egg-film, 295 

Egyptian ophthalmia, 277 

Elastic fibres, demonstration of, 786 

Electric ophthalmia, 514 

Electricity in herpes zoster ophthalmicus, 161 
in lacrimal stricture, 230, 238 
in opacities of the cornea, 350 
in paralytic strabismus, 668 
Electrolysis in angiomas, 175 
in detachment of the retina, 523 
in fistula of the cornea, 349 
in trichiasis, 190, 201 
in granular conjunctivitis, 283 
in keloid of eyelid, 174 
in lacrimal diseases, 230, 238 
in molluscum epitheliale, 172 
in neevus vasculosus, 175 
in xanthoma, 172 
Electromagnet, giant, 371 
of Haab. 371 
of Hirschberg, 371 
of Johnson, 371 
of Lippincott, 371 
of Sweet, 371 
results of use of, 372 

Elephantiasis Arabum of eyelids, sporadic 
type, 169 

tropical type, 169 
Ellett, 350 
ELSCHNIG, 224, 496 

Embolism of central retinal artery, 494 
Embryotoxon, 303 
Emmetropia, 691 
ophthalmoscopy in, 142 
retinal image in, 139, 691 
skiascopy in, 147, 148 
Emphysema of conjunctiva, 293 
of eyelids, 184 
Empyema of antrum, 634 
of frontal sinus, 634 
of sphenoidal sinus, 634 
Encanthis, 296 
Encephalocele, 618 
Encephalopathy, lead, 508 
Enchondroma of orbit, 623 
Endarteritis, 490, 496 
Endocarditis, 496 
Endogenous panophthalmitis. 429 
Endothelioma of orbit, 621, 625 
Enophthalmos, 101, 589, 640, 649 
Entropion, 193, 223, 271, 280, 294, 295 
congenital, 159 
from trachoma, 193, 280 
operations for, 203 
organic, 280 
senile, 193 
spasmodic, 193 

Enucleation of eyeball, 606, 607 
accidents during or after, 609 
Arlt’s method, 608 
Bonnet's method. 608 
indications for, 606 
Eosin. 782 

Ephidrosis. See Hyyeridrosis. 

Epibulbar tumors, 244, 246 
Epicanthus, 159 
operations, 206 
Epidemic ophthalmia, 252 
Epilepsy, 679, 744 

Epileptic seizure in cataract extraction, 454 
Epiphora, 222, 226, 227 
Episcleral tissue, 33 
Episcleritis, 361 , 

fugacious, 363 
partialis fugax, 363 
Epithelial xerosis, 288 
Epithelioma of conjunctiva, 246 
of cornea, 304 
of eyelids, 176 
Equator, 72 


Equilibrium test for heterophoria, 676 
Ergot, 580 

amblyopia from, 542 
Erismann, 707 
Erlitzki’s fluid, 774 
Errors of refraction, 686 
Erysipelas of eyelids, 163 
Erythropsia, 476, 556, 559, 748 
after cataract operation, 559 
Eserin, 267, 576 
after cataract extraction, 454 
and cocain in glaucoma, 576 
in glaucoma, 574 
Esophoria, 670 
Esotropia, 670, 671 
Essential phthisis bulbi, 436 
Essential shrinking of conjunctiva, 165, 193, 275 
Ether, 754 

Ethmoidal sinuses, diseases of, 633 
Ethyl bromid, 754 
Eucain, 754 

Eversbusch, 196, 199 
Eversion of eyelids, 88 
Evetsky, 224, 419 
Evisceration of the eye, 610 
Hall’s method, 611 
Mules’s method, 611 
Eviscero-neurotomy, 612 
Ewing, 121, 206, 306 
Examination of the eye, 85-157 
anterior chamber, 94 
caruncle, 92 
children’s eyes, 88 
ciliary body, 99 
color-sense, 127 
conjunctiva, 89 
cornea, 92 
crystalline lens, 98 
eyelashes, 86 
eyelids, 87 
field of vision, 124 
fundus oculi, 134, 340 
iris, 95 

lacrimal apparatus, 91 
lens, 98 

light-sense, 127 
macula lutea, 139 
muscle-balance, 101 
muscle-power, 108 
ophthalmoscopic, 135 
optic nerve, 139 
orbit, 100 
pupil, 95 

pupillary area, 98 
refraction, 115, 132, 141, 144-151 
sclerotic, 92 
visual acuity, 118 
visual field, 124 
vitreous humor, 99 
Excavation of optic-neiye head, 570 
atrophic, 570 
glaucomatous, 570 
physiologic, 570 
Excision of cul-de-sac, 283, 299 
of eyeball. See Enucleation. 
of lacrimal sac, 234 
of superior sympathetic ganglion, 589 
Exciter, 594 
Exciting eye, 594 
Exenteration of the orbit, 653 
Exfoliation of the iris, 376 
Exophoria, 670 

Exophthalmic goitre, 641, 745 
eye symptoms of, 745 
nature of, 645 
prognosis of. 645 
symptoms of, 641 
treatment of, 645 
Exophthalmos, 100, 271, 649 
intermittent. 640 
pulsating, 638 
Exothyropexy, 645 
Exotropia, 670, 671 
Expression, 283 
operation in trachoma, 283 
External ophthalmoplegia, 665 
External rectus muscle, 14 
paralysis of. 661 

Extirpation of lacrimal sac, 234 
Extraction of intra-ocular cysticercus, 478 




802 


INDEX. 


Extraction of immature cataract, 461 
of senile cataract, 451 
Exudative chorioiditis, 420, 422 
Eye, anatomy of, 8-61 
cardinal points of, 63 
nodal point of, 62, 65, 66 
optical defects of, 68 
-shade, 761 

Eyeball, anatomy of, 29 
atrophy of, 436 
dislocation of, 647 
foreign bodies in, 370 
spontaneous rupture of, 418 
Eyelids, abscess of, 162, 194 
absence of, 158 
acne rosacea of, 180 
Adams’s operation on, 208 
adenoma of Meibomian gland of, 178 
albinism of, 170 
Aleppo boil of, 161 
alopecia areata of, 182 
alopecia of, 182 
Amboyna button of, 161 
anatomy of, 24 
ankyloblepharon, 159, 190 
anomalies of, 158 
anthrax of, 162 
argyria of, 167 
arteries of, 28 
asteatosis of, 180 
Biskra button of, 161 
Blasius’s operation on, 214 
blastomycetic dermatitis of, 166 
blepharitis acarica, 186 
marginalis, 185 
squamosa, 185 
ulcerosa, 185 
blepharochalasis, 184 
blepharophimosis, 159, 1S8 
congenital, 159 
blepharospasm, 189 
bullous affections of, 165 
burns of, 194 
cancroid ulcer of, 177 
carbuncle of, 162 
carcinoma of, 176 
chalazion, 181 
operations, 195 
chancre of, 173 
chloasma of, 167 
chromidrosis of, 179 
colloid degeneration of, 179 
coloboma of, 158, 192, 193 
congenital anomalies of, 158 
hyperkeratosis of, 167 
ptosis of, 159 
contusion of, 193 
cornu cutaneum of, 168 
cryptophthalmos, 158 
cyst of, 167 
cysticercus of, 183 
Darier’s disease of, 172 
Delhi boil of, 161 
dermatitis of, 165 
blastomycetic, of, 166 
medicamentosa, of, 165 
dermoid cyst of, 167 
Dieffenbaeh’s operation on, 208 
discoloration of, 167 
distichiasis of, 159, 190 
drooping of, 191 
ectropion of, 192, 2Q7 
congenital. 159 
eczema of, 160 
edema of, 168, 567 
solid, 169 

elephantiasis of, 169 
emphysema of, 184 
entropion of, 193 
congenital, 159 
epicanthus, 159 
operations, 206 
epithelioma of, 176 
erysipelas of, 163 
erythema of, 160 

Ewing’s operation on low'er lid, 206 

examination of, 87 

favus of, 183 

fibroma of, 175 

fissures of, 161 


Eyelids, fistula of, 159 
foreign bodies in, 195 
frambesia of, 161 
freckles of, 170 
Fricke’s operation on, 214 
Fuchs’s operation on, 200 
furuncle of, 161 
furunculus orientalis of, 161 
gangrene of, 179 
gumma of, 173 

gunpowder-grains in, 167, 195 
hailstone of, 181 
hare’s eye, 187 

Harlan’s operation on the upper lid, 205 

Hasner d’Artha’s operation on, 214 

hernia of fatty tissue of, 168 

herpes of, 163 

hives of, 160 

hordeolum of, 166 

Hotz’s operations on, 204, 210 

hyperemia of margins of, 185 

hyperidrosis o"f, 179 

hyperkeratosis of, 167 

hysteric alopecia of, 182 

impetigo of, 161 

in glaucoma, 567 

injuries of, 193 

intermarginal line of, 26 

Jacob’s ulcer of, 177 

Jaesche-Arlt operation on, 202 

Kaposi’s disease of, 171 

keloid of, 174 

keratosis follicularis of, 172 
Knapp’s operation on, 215 
Kuhnt’s operation on, 210 
lacerations of, 193 
lagophthalmos, 187 
lentigo of, 170 
leprosy of, 174 
lichen of, 165 
tropicus of, ISO 
lipoma of, 168 

lupus erythematosus of, 172 
vulgaris of, 173 
lymphangioma of, 175 
lymphatics of, 28 
lymphoma of, 175 
malignant pustule of, 162 
marginal blepharitis, 185 
measles of, 184 
Meibomian cyst of, 181 
microblepharon, 159 
miliaria of, 180 
milium of, 180 

molluscum contagiosum of, 172 
epitheliale of, 172 

Mules’s operation for ptosis of, 198 
Muller’s operation on, 210 
muscles of, 26 
naevus pigmentosus of, 170 
vascuiosus of, 175 
nerves of, 28 
neurofibroma of, 175 
noma of, 179 
operations on the, 195 
Panas’s operation on upper lid, 197 
parasitic skin diseases of, 182 
pemphigus of, 165 
perifolliculitis of, 166 
phagedenic ulceration of, 179 
phosphoridrosis of, 179 
phtheiriasis of, 186 
pian of, 161 

plexiform neuroma of, 175 
“prickly heat” of, 180 
psorophthalmia, 185 
ptosis of, 159, 191 
punctured wounds of, 193 
rhagades of, 161 

Robertson’s operations on the, 208, 209 
rodent ulcer of, 176, 177 
rubeola of, 184 
Sanson’s operation on, 208 
sarcoma of, 177 
scalds of, 194 
scarlatina of, 184 
seborrhea of, 180 
of palpebral margins, 185 
serpiginous synhilide of, 173 
siderosis of, 167 




INDEX. 


803 


Eyelids, skin diseases of, 160 
Snellen’s operations on, 203, 207 
spontaneous gangrene of, 179 
steatoma of, 180 
structure of, 25 
stye, 166 
sudamina of, 179 
sycosis tarsi, 185 
symblepharon, 190 
syphilis of, 173 

Tansley’s operation on upper lid, 197 
tarsal tumor, 181 
tarsitis, 162 
tarsorrhaphy, 200 
tattooing of, 167 
tinea tarsi, 185 
trichiasis, 190 
operations for, 201 
tuberculosis of, 172 
ulcer, Jacob’s, 177 
uridrosis of, 179 
urticaria of, 160 
vaccinia of, 184 
varicella of, 184 
varicose veins of, 170 
variola of, 183 
veins of, 28 
verruca of, 168 
vitiligo of, 170 

von Ammon’s operations on, 201, 208 
von Graefe’s operation on, 196, 200 
von Langenbeck’s operation on, 208 
Wicherkiewicz’s operation on, 207 
Wilder’s operation on upper lid, 196 
wounds of, 193 
xanthoma of, 172 
xeroderma pigmentosum, 171 
yaws of, 161 
Eyre, 289 

Facial palsy, 668 
Facultative hypermetropia, 697 
Falcone, 292 

False muscular projection, 659 
passage by probe, 227, 236 
Family ataxia, 742 
Far point, 68 
Fascia, oculo-orbital, 11 
inflammation of, 632 
tarso-orbital, 196, 197, 205, 211 
Fascicular keratitis, 273 
palsies, 666 

Fat and fatty degeneration, demonstration of, 
786 

Fatigue-field, 746 
Fehr, 243 

Feigned blindness, 747 
Ferri, 643 
Ferry, 219 
Fetal eye-cup, 4 
lens, dimensions of, 51 
optic nerve, 5 
retina, 5 

vitreous humor, 3 
Fibres of crystalline lens, 52 
of Miiller, 44 
of oDtic commissure, 47 
Fibrillary contraction of orbicularis muscle, 
189 

Fibrin, demonstration of, 787 
Fibrinous iritis, 385 
Fibroma of conjunctiva, 240 
of cornea, 305 
of eyelids, 175 

Fibromatosis nervi optici, 530 
Fibrous coat of eye, 29 
Fick, 345. 385 
Field of fixation, 658 
of vision, 77 
examination of, 124 
in glaucoma, 569, 570, 572, 576 
in optic-nerve atronhy, 545 
in optic neuritis, 533 
in toxic amblyopia, 542 
method of examining, 124 
reversal of, 558 
Fifth nerve, 18 
Filamentary keratitis, 332 
Filaria in anterior chamber, 396 
in lens, 471 


Filaria loa, 285 
subconjunctival, 285 
Filehne, 745 

Filix mas, amblyopia from, 542 
Filtration angle. See Iridocorneal angle. 
chemosis, 293 
edema, 457 
Finsen’s light, 177 
First principal focus, 63 
Fisch, C., 181 
Fischer, 496 

Fischer, W. E., chapter contributed by, 772 
Fisher, W. A., 371, 372 
Fissure, fronto-maxillary, 159 
sphenoidal, 9 
spheno-maxillary, 10 
Fistula, lacrimal, 227 
of eyelid, 159 
of lacrimal gland, 221 
of the cornea, 342, 346 
spurious, 346 
treatment of, 347 
true, 346 

Fistulous staphyloma, 346 
Fitzgerald, 642 
Fixed cells of cornea, 30 
Fixing eye specimens, 773 
Flemming’s solution, 775 
Flexner, 482 
Flimmerskotom, 557 
Fluorescin,'93, 292 
Focal lesions of the brain, 737 
Focus, anterior principal, 63 
first principal, 63 
posterior principal, 62 
second principal, 63 
Follicles in drug conjunctivitis, 259 
Follicular conjunctivitis, 254, 257 
diagnosis, 258 
etiology, 258 
pathology, 258 
prognosis, 258 
symptoms, 258 
treatment, 258 
ophthalmia, 257 
trachoma, 257 
Folliculosis, 257 
Fontana, spaces of, 31, 41 
Foramina of orbit, 9 
Foreign bodies in anterior chamber, 396 
in ciliary body, 409 
in conjunctiva, 294 
in cornea, 354 
in crystalline lens, 472 
in eyeball, 370 
in eyelids, 195 
in iris, 395 

in lacrimal passages, 223 
in orbit, 650 
in sclera, 370 
in vitreous humor, 480 
localization of, 353 
magnetic, 371 
non-magnetic, 373 
Formalin, 266 
Formol, 774 
-Muller fluid, 774 
Form-sense, 118 

Fornix, examination of lower, 89 
examination of upper, 89 
Forster, 423, 467, 501, 509, 510 
Fourth nerve, 18 
paralysis of, 734 ► 

Fovea centralis, anatomy of, 42, 46 
reflex of, Plate V, 61 
Fox, L. W., 460, 615, 685 
Fracture of ethmoid bone, 293, 649 
of lamina cribrosa, 649 
of optic canal, 649 
of orbital bones, 648 
Francisco, 268 
Freund, 739 

Fricke’s blepharoplasty, 213, 214 
Fridenberg, 152, 513 
Friedenwald, 387, 558 
Friedreich’s ataxia, 742 
Fries, 553, 555 
Fromaget, 221 
Frontal bone, 8 
nerve, 18 






S04 


INDEX. 


Frontal sinus, diseases of, 633 
Fronto-maxillary fissure, 159 
Frost, 421, 499, 515, 612 
method of implantation of sphere, 612 
Friijahr’s catarrh. See Vernal conjunctivitis. 
Fuchs, 41, 164, 200, 286, 287, 288, 360, 415, 418, 
486, 492, 498, 513 
Fuchsin, 781 

Fugacious episcleritis, 363 
Functions of the iris, 70 
of the retina, 77 
Fundus oculi, anatomy of, 56 
appearance of normal—Plates II, III, and IV 
examination of, 140 
normal, 56 

of albino—Fig. 2, Plate III 
of brunette—Fig. 2, Plate II 
variations in, 59 
Fundus-reflex test, 144 
Fungus haematodes oculi, 482, 484 
trichophyton, 186 
Fusion of images, 674 

Gaillard, 206 

Galezowski, 220, 250, 299, 389, 496, 49S, 505, 522 
Gallenga, 262 
Gamma, angle, 69, 713 
Gamo Pinto, 316 
Ganglion, ciliary, 17 
Gasserian, 164, 200, 317 
inferior cervical, 19 
lenticular, 17 
middle sympathetic, 19 
of Meckel, 19 
ophthalmic, 17 
superior cervical, 19 
Gangrene of eyelids, 179 
Gargarin, 315 
Gasparini, 252 
Gay, 550 

Gayet’s iridectomy, 399 
operation, 355, 35S 
Gelsemium, 190 

General paralysis of the insane, 743 
Gensoul, 229 
Gerard-Marchant, 584 
Gerlach, illustration from, 12 
Gerontoxon corneae, 349 
Gescheidt, 489 
Gessner, 641 
Giant magnet, 371 

Gifford, 251, 252, 256, 275, 276, 498, 605, 615 
reflex, 98 
Gilfillan, 418 

Gillet de Grandmont, 199, 525 
Gimitrto, 517 
Glands, acino-tubular, 26 
cervical, 289 
ciliary, 38 
lacrimal, 7, 22 

of Krause. See Glands, acino-tubular. 
of Meibomius, 26 
of Moll, 26 
of Waldeyer, 26 
of Zeiss, 166 

pre-auricular, 173, 176, 184, 263, 275, 289, 290 
submaxillary, 176, 184, 275, 289 
Glass eyes. See Artificial eyes. 
shield after symblepharon operation, 299 
vitreous, 611 

Glasses. See Lenses and Spectacles. 
Glaucoma, 418, 562 
absolutum, 580 
acute inflammatory, 577 
after cataract operation, 458 
anatomic changes in, 565 
anterior, 569 

anterior chamber in, 568 
ciliary arteries in, 567 
ciliary veins in, 567 
anterior sclerotomy in, 591 
aqueous humor in, 569 
arecolin in, 576 
atropin in, 585 
cataract in, 568, 569 
cervical sympathetic in, 565 
changes in intra-ocular contents in, 569 
chorioid in, 568 
chronic irritative, 576 
ciliary body in, 568 


Glaucoma, clinical varieties of, 572 
cocain in, 576 
congenital, 582 
cornea in, 567 
crystalline lens in, 568 
cyclicotomy for relief of, 590 
de Wecker’s method in, 592 
definition of, 562, 563 
diagnosis of, 573 
dilation of pupils in, 568 
enucleation for, 581 
eserin in, 576 
etiology of, 563, 578 

excision of cervical sympathetic ganglion in, 
586 

eyelids in, 567 

general considerations of, 562 
halo in, 567 

Hancock’s operation in, 590 
hemorrhages in, 577 
hemorrhagic, 493, 577 
heredity of, 563 
infantile, 582 

intra-ocular tension in, 562, 567, 572, 577, 
580, 582, 5S4 

iridectomy in, 574, 577, 585 
iris in, 568 
lens in, 568 

macroscopic changes in eyeball in, 506 

massage in, 576 

miotics in, 576 

nasal disease in, 564 

operations for relief of, 584 

ophthalmoscopic signs of, 570 

optic nerve in, 569 

pain in, 572, 576, 577 

pathology of, 565, 578 

pilocarpin in, 576 

posterior, 569 

posterior sclerotomy in, 591 

post-iritic, 387 

prevention of, 581 

prognosis of, 579 

Quaglino’s method in, 591 

retina in, 569 

sclera in, 567 

sclerotomy in, 591 

secondary, 458, 584 

signs of, ophthalmoscopic, 570 

simplex, 572 

sympatheticectomy for, 575, 577 
symptoms of, 572, 576 578 
treatment of, 674, 577, 580, 581 
unaffected eye in, 581 
Glaucomatous cataract, 568 
degeneration, 580 
excavation, 570 

eyes, anatomic changes in, 567 
Glioma of the retina, 482 
Globe. See Eyeball. 

Glorieux, 259 

Glycogen, demonstration of, 790 
Glycosuric cataract, 449 
retinitis, 503 

Goldberg. Harold G., chapter contributed 
by, 756 

Goldzieher, 23, 275, 433 
Golgi, 43 
Gonin, 549 
Gonococcus, 267 
Gonorrheal conjunctivitis. 262 
iridochorioiditis, 427 
ophthalmia of the adult, 263 
of the newborn, 267 
Gonzales, 539 
Gordon, 645 
Gossetti, 270 
GOULD, 377, 548, 551 
Gouty retinitis. 511 
Gowers, 642, 734 
Gradle, 273, 274 
Graduated tenotomy, 683 
Grafting of skin, Italian method. 215 
le Fort’s method, 216 
Ollier’s method, 2’3 
Reverdin's method, 213, 217 
Tagliacozzi’s method, 213 
Thiersch’s method, 217 
Grafts in ectropion operations, 208 
in pterygium operations, 297 




INDEX. 


805 


Grafts in symblepharon operations, 299 
Gram-Weigert method, 791 
Grandclement, 268, 390, 393 
Granular conjunctivitis, 277 
Granulation, false, 258 
true, 258, 277 

tumors of conjunctiva, 241 
Granuloma of conjunctiva, 241 
of iris, 380 

Gratiolet, radiations of, 82, 736 
Grattage, 2S3, 301 
Graves’s disease, 745 
Greeff, 45, 366 
Green vision, 559 
Grenacher, 780 

Griffith, A. Hill, 339, 415, 426, 427, 642 
Griffith’s method, 776 
Grill-like keratitis, 339 
Grindon, J., illustration from, 178 
GRIZON, 525 

Groenouw, 263, 269, 504, 505, 510, 553, 554 
Grosz, 553 
Gruening, 531 
Guiata, 237, 420 
Gumma of chorioid, 419 
of ciliary body, 405 
of conjunctiva, 292 
of eyelid, 173 
of iris, 386 
of orbit, 629 
Gummatous iritis, 386 
Gumpper, 601 
Gunn, 515, 540 
Gunn’s dots, 515 
Gurwitsch, 21, 508 
Gymnastic exercise by prisms, 6S0 

Haab, 339, 372, 373, 380, 432, 494, 600 
magnet operations, 372 
Hack, 642 
Haglund, 269 

Hair of caterpillar in conjunctiva, 285 
Hair-optometer, 122 
use of, 122, 123, 124 
Hala, 181 
Hale, 390 
Half-sight, 558 
Hall, Ernest, 611, 613 
Halo in glaucoma, 567 
Hamilton, 471 

Hancock’s operation for glaucoma, 590 
Hann, 525 
Hansell, 252 

Hardening of eye specimens, 777 
Harlan, 205, 298, 400 
Harlan’s operation for entropion, 205 
for symblepharon, 299 
Hartley, 637 
Hartridge, 438 
Hasner, 361 

Hasner d’Artha’s blepharoplasty, 214 
Haug, method of, 776 
Head, 164 

Healing of corneal wounds, 353 
Hebra, 187 
ointment of, 187 
Heine, 67 

Heisrath’s operation, 299 
Helmholtz, 51, 66, 67, 82, 551 
ophthalmoscope of, 134 
theory of accommodation of, 66 
Helmholtz-Young theory of color-percep¬ 
tion, 551 
Hemalaun, 779 
Hemeralopia, 557 
Hemianopsia, 736 
absolute, 736 
altitudinal. 736 
binasal, 736. 738 
bitemporal, 736, 738 
complete, 736 
homonymous, 736 

diagram illustrating. 737 
in focal brain disease, 738 
incomplete, 736 
inferior, 737 
lesions producing, 736 
superior, 737 

Hemianoptic pupil-symptom of Wernicke, 739 
pupillary inaction, 97 


Hemorrhage, amblyopia from, 553 
beneath conjunctiva, 293 
chorioidal, 433 

during cataract extraction, 454 

following cataract extraction, 455 

in glaucoma, 577 

into chorioid, 433 

into cornea, 353 

into orbit, 637, 646 

into retina, 492 

into sheath of optic nerve, 549 
into vitreous humor, 476 
Hemorrhages in myopia, 712 
Hemorrhagic glaucoma, 493, 577 
retinitis, 492 

Hemostasis, artificial, 755 
Henle, 46, 55, 57 
Henschen, 736 
HERBERT, 276, 281, 456, 457 
Hering, 152 
experiment of, 152 
theory of color-blindness, 551 
Hernia of Descemet’s membrane, 308 
of iris, 395 

of orbital fatty tissue, 168 
Herpes conjunctivas, 274 
cornese, 333, 336 
frontalis, 163 

zoster ophthalmicus, 163, 743 
Hertel, 490 
Hess. 199 
Heterochromia, 376 
Heterograft, 216 
Heterophoria, 670, 675 
diagnosis of, 675 
graduated tenotomy for, 6S3 
symptoms of, 679 
tests for, 675, 676, 677 
treatment of, 679 
varieties of, 679 

Heterophthalmos. See Heterochromia. 

Heterotropia, 670 

Hetol, 302 

Heuse, 605 

Heustis, 242 

Heymann, 349, 505 

Hexagonal pigment-cells of the retina, 44 

Higgins, 224, 642 

Hilbert, 2S4 

Hippus, 96, 396 

Hirsch, 512, 513 

Hirschberg, 417, 430, 479, 485, 503, 553, 555, 
600 

magnet of, 371 
Hirst, 617 
His, 8, 65 

History of cases, 85 
Hives, 160 
Hoffmann, 271 
Holden, 417, 513, 518, 519, 555 
“Holes” in the macula, 522 
Holmes, C. R., 231, 284 
Holocain, 255, 295, 754 
Homatropin, 133 
Hordeolum, 166 
Horner, 275, 345, 380, 546 
muscle of, 24 

Hornv growths. See Cornu cutaneum. 
Horopter, 75, 76 
Hortsmann, 522 

Hot applications in conjunctivitis, 251, 254, 
257, 270 

in dacryocystitis, 226 
in episcleritis, 363 
in iritis, 392 
in keratitis, 314 
in orbital cellulitis, 632 
in orbital periostitis, 629 
in scleritis, 366 
“Hot eye,” 363 

Hotz, 204, 205, 210, 211, 212, 213, 297, 299 300 
494 

operation of, for ectropion, 210 
entropion, 204 
Howe, Lucien, 17, 510 
Huizinga, 612 
Hulen, 110 
Humor, aqueous, 396 
vitreous, 54 
diseases of, 473 






SOG 


INDEX. 


Hutchinson, 163, 388, 424 
teeth, 323 

Hyalin and colloid degeneration, demonstra¬ 
tion of, 788 
Hyalitis, 387, 473, 487 
acute suppurative, 487 
suppurative, 474 
Hyaloid artery, 473 
persistent, 473 
membrane, 55 
Hydrocephalus, 743 
Hydrogen peroxid, 776 
Hydrophthalmos, acquired, 582 
congenital, 582 
treatment of, 583 
Hygiene of the eyes, 756 
Hyoscin, 133 
Hyoscyamin, 133 
Hyperboloid lenses, 345 
Hyperemia, conjunctiva, 243 
of chorioid, 699 
of conjunctiva, active, 249 
passive, 250 

of optic-nerve head, 534 
posterior conjunctival, 248 
of retina, 489, 490 
Hyperesophoria, 101, 670 
Hyperesthesia of retina, 526 
Hyperexophoria, 101, 670 
Hyperidrosis, 179 
Hyperkeratosis, 167 
Hypermetropia, 692 
absolute, 697 
anele alpna in, 698 
definition of, 692 
diagnosis of, 699 
diminishing, 692 
etiology of, 694 
facultative, 697 
in strabismus, 698 
latent, 697 
manifest, 697 
ophthalmoscopy in, 142 
pathology of, 694 
relative, 697 
retinal image in, 696 
symptoms of, 695 
total. 697 
treatment of, 700 
Hypermetropic disc, 542 
Hyperopia. See Hypermetropia. 

Hyperostosis, 630 
Hyperphoria, 670 

Hypertrophy of lacrimal gland, 220 
Hypertropia. 670 
Hyphemia, 394 
Hypometropia. See Myopia. 

Hypopyon in corneal ulcer, 306 
-keratitis, 311 
source of, 306 
Hypotony, 584 
Hysteria, 746 
Hysteric alopecia, 182 
amblyopia, 526, 558, 746 
blepharospasm, 189 
blindness during the puerperium, 509 

Ichthyol, 283 
Ichthvosis, 280 
Identical points, 75 
Idiocy, amaurotic family, 512 
Illumination by retinoscopy mirror, 93 
focal, 93 
oblique, 93 

Image, inversion of, 81 
retinal, 65 

size of ophthalmoscopic, 139 
Images, mechanism of formation of, 62 
produced by lenses, 689 
Imbedding, 777 
Impetigo, 161 

Implantation of artificial vitreous in sclera, 
611 

into Tenon’s capsule, 612 
cyst of iris, 377 

Inch system of numbering glasses, 691 
Index of refraction, 687 
of air, 64 

of aqueous humor, 64 
of cornea, 64 


Index of crystalline lens. 64 
of reduced eye, 65 
of vitreous humor, 64 
of water, 64 

Indications for enucleation, 606 
Indirect ophthalmoscopy, 136, 137, 133 
Indirect vision, 79 
Inequality of pupils, 96 
Infantile amaurotic family idiocy, 512 
Infantile paralysis, 743 
Infected wounds of eyeball, 370 
Inferior oblique muscle, 15 
paralysis of, 662 
rectus muscle, 15 
paralysis of, 662 
Infiltration anesthesia, 754 
Infra-orbital foramen, 10 
nerve, 10 
vessels, 10 

Injected blood-vessels of iris, etc. (Fig. 35), 36 
Injections, subconjunctival, 301 
Injuries of chorioid, 433 
of ciliary body, 409 
of conjunctiva, 294 
of cornea, 351 
of crystalline lens, 471 
of eyelids, 193 
qf iris, 394 
of optic nerve, 560 
of orbit, 646 
of retina. 521 
of sclera, 368 
Insanity, 743 

Instruments, preparation of, 752 
Insufficiency of ocular muscles. See Hctero- 
phoria. 

Intermarginal line, 26, 202. 

Internal rectus muscle, 14 
advancement of, 684 
paralysis of, 661 
tenotomy of, 681 
Interorbital space, 11 
Intracranial tumor, 508, 534 
Intra-ocular cysticercus. 381, 418 478, 487 
hemorrhage, 394, 433, 454, 455, 476, 492, 494, 521 
injections, 605 
tension, normal, 562 
tumors, 377, 378, 380, 404, 414, 482 
Inversion of the image, 81 
of the iris, 395 

Inverted image of fundus, 136 
Iodic acid, 283 

Iodid of potassium, 292, 293, 497, 511, 666 
Iodin injections in retinal detachment, 525 
Iodoform, 290, 301, 475 
amblvopia from, 542 
in lymphoma of the conjunctiva, 276 
use of. in anterior chamber, 433, 456 
Iona, 270 

Iridal part of the retina, 46 
Iridectomy, 397, 585 
accidents during, 399 
Deschamps’s method, 400 
Gayet’s method, 399 
in aphakic eyes, 400, 585 
in cataract extraction, 453, 458 
in corneal diseases, 316, 330, 336, 343, 348, 351, 
353 

in corneal opacity, 351 
in detachment of the retina, 525 
in glaucoma, 399, 585 
in hemorrhagic glaucoma, 580 
in hydrophthalmos, 583 
in iritis, 393 

in juvenile cataract, 463 

in obliteration of the anterior chamber, 399 

in prolapse of iris, 395 

in pterygium, 287 

in sympathetic ophthalmitis, 605 

in uveite irienne, 393 

instruments for, 398 

intra-ocular hemorrhage after, 586 

method of performing, 398 

optical, 397 

in cataract extraction, 458 
preliminary to cataract extraction, 399, 459 
therapeutic, 398 
Iridenkleisis, 394, 400 
Irideremia. See Aniridia. 
traumatic, 394, 395 




INDEX. 


807 


Iridesis. See Iridodesis. 

Iridocapsulotomy, 401 
Iridochorioiditis, 387, 427 
gonorrheal, 427 

Iridocorneal angle (Fig. 31), 32 
Iridocyclitis, 387, 418, 595 
after cataract extraction, 456 
endogenous, 409 
plastica, 408 
serous, 406 

spontaneous chronic, 606 
sympathetic. See Sympathetic ophthalmitis. 
Iridocystectomy, 402, 403 
Iridodesis, 397 
Iridodialysis, 394, 400, 405 
Iridodonesis, 396 
Irido-ectomy, 402 

Iridoplegia. See Paralytic mydriasis. 
Iridotomy, 400 
Iris, absence of, 376 
absence of pigment in, 376 
adhesion of, to the cornea, 377 
anatomy of, 33 
anomalies of, 374 
anteversion of, 394 
arteries of, 34 
blood-vessels of, 34, 35 
bombe, 387, 400 
bridge coloboma of, 374 
cholesteatoma of, 378 
chromatic asymmetry of, 376 
coloboma of, 374 
color of, 33 

complete detachment of, 394 
congenital anomalies of. 374 
congenital atrophy of, 377 
congenital tumors of, 377 
contraction of, 71, 96 
cysticercus of, 381 
cysts of, 377 
development of, 4 
-diaphragm, 147 
dilation of, 71, 96 
dilator muscle of, 34 
diseases of, 374-403 

displacement of. See Injuries of the iris. 
exfoliation of, 376 
filaria of, 381 
foreign bodies in, 395 
functional disorders of, 396 
functions of, 70 
granuloma of, 380 
gummatous inflammation of, 386 
hyperemia of, 382 
implantation cysts of, 377 
-inaction of Wernicke, 97, 739 
incarceration of. See Prolapse of iris. 
inflammation of, 381 
injuries of, 394 
'inversion of, 395 
laceration of sphincter of, 304 
leprosy of, 380 
lymphomata of, 380 
melanoma of, 376 
mobility of, 96 
motor disturbances of, 396 
muscle-fibres of, 33, 34 
myomata of, 380 
myosarcomata of, 380 
nerves of, 35 
nevus of, 380 
operations on, 397 
papilloma of, 376 
paralysis of, 96, 668 
pearl-cysts of, 378 
physiology of, 70-72 
pigment of, 34 
prolapse of. 395 
after cataract extraction, 454 
radial section of (Fig. 33), 34 
retention cysts of, 377 
rupture of-, 394 
sarcoma of, 378 
serous cysts of, 377 
sphincter of, 34 
total prolapse of, 309 
transfixion of, 400 
tremulous. See Iridodonesis. 
tubercle of, 380 
tumors of, 377 


Iris, unusual tumors of, 380 
vascular tumors of, 380 
wounds of, 394 
Iritis, 26o, 289, 291, 293, 381 
after cataract operations, 456 
causes of, 3S8 
complications of, 386, 387 
congenital, 388 
diabetic, 389 
diagnosis of, 383 
etiology of. 388 
fibrinous, 385 

gonorrheal. See Gonorrheal iridochorioi¬ 
ditis. 

gummatous, 386 
infectious, 393 
iridectomy in, 393 
operative treatment of, 393 
papulosa, 386 
parenchymatous, 385 
pathology of, 386 
plastic, 384 
prognosis of, 390 
purulent, 385 
rheumatic, 388 
senile, 389 
serous, 384 
sequelae of, 387 
spongy, 385 
suppurative, 385 
sympathetic, 599 
serous, 599 
symptoms of, 381 
syphilitic, 386 
traumatic,' 388 
treatment of, 391 
tubercular, 386 
varieties of, 384 
lritomy, 400 

Iron, demonstration of, 790 
Irradiation, 81 
Irregular astigmatism, 723 
Irritation of the retina, 526 
Ischemia of retina, 489 
Isolated dots in the retina, 515 
Iwanofp, 281 
illustrations from, 39 

Jaborin, 576 

Jackson, E., 94, 135, 747, 753 
binocular magnifier of, 94, 95 
Jackson, Hughlings, 537 
Jacob’s ulcer, 176, 177 

Jacobson, diffuse syphilitic retinitis of, 501 
Jaeger, 58, 203, 425 
Jaencke, 525 
Jaesche, 300 

Jaesche-Arlt operation for trichiasis, 202 
Jamaica ginger, amblyopia from, 544 
Jansson, 157 
Javal,, 73 

Javal-Schioetz ophthalmometer, 116 

Jennings, J. E., illustrations from, 78, 82, 571 

Jensen, 525 

Jequirity, 269, 284 

Jessup, 496 

Jeunet, 584 

JOCQS, 467, 468 

Johnson, 371, 583 

Johnson, G. Lindsay, 60, 412 

JONNESCO, 584 

JUDA, 243 

JULER, 258 

Junction, corneoscleral, 40 
Jung, 486 
Junius, 252 
Juvenile cataract, 463 

Kagenaar, 177 
Kaiserling’s method, 773 
Kalt, 225, 459 
suture, 459 

Kataphoria. See Gataphoria. 

Katatropia. See Catatropia. 

Keber, illustration from, 174 
Keloid, 174 
Keratectasia, 346 
Keratite en bandelette, 334 
quadrillee, 339 
Keratitis, 305 




SOS 


INDEX. 


Keratitis after cataract extraction, 456 
aspergillar, 330 
bullosa, 329 
calcareous, 334 

dendritica exulcerans mycotica, 331 
disc-like, 339 
e lagophthalmo, 317 
eczematous, 320 
fascicular, 273, 320 
filamentary, 332 
gitterformige, 339 
grill-like, 339 
hypopyon, 311 
interstitial, 321 
diagnosis of, 324 
etiology of, 322 
pathology of, 324 
prognosis of, 324 
symptoms of, 322 
treatment of, 325 
lagophthalmic, 317 
macular, 333 
malarial, 331 
marginal, 337 
phlyctenular, 320 
marginalis profunda, 337 
neuroparalytic, 316 
neuropathic, 316 
nodular, 333 
nummular, 333 
opacities due to, 350 
parenchymatous, 321 
phlyctenular, 320 
diagnosis of, 321 
pathology of, 321 
prognosis of, 321 
symptoms of, 320 
treatment of, 321 
profunda, 321 
punctata, 406. 407 
profunda, 333 
superficialis (Fuchs), 333 
ribbon-shaped, 334 
sclerosing, 364 
scrofulous, 320 
sequelae of, 309 
specific. 321 
striate, 338 
striped, 338 
strumous, 320, 321 
subepithelialis centralis, 333 
superficial punctate, 333 
suppurative, 308 
symptoms of, 305 
traumatic, 351 
trophica, 334 

ulcerativa marginalis, 337 
vascular, 325 
vesiculosa, 329 
xerotic, 31S 
zonular, 334 

Keratocele, 308, 342, 346 
Keratoconus, 303, 344 
Keratoglobus, 303, 345 
Kerato-iritis, 305 
Keratomalacia, 288, 318 
Keratometry, 115 
Keratomycosis aspergillina, 330 
Keratonyxis, 462 
Keratoplasty, 351, 360 
Keratoscopy, 145 
Keratotomy, 357 
Kerectasia, 346 

Kerschbaumer, 244, 245, 246, 379, 415 
Kindergartens, 757 
Kixgdon, 512, 513 
Kipp, 223, 379, 419, 430 

Klebs-Loeffler bacillus, 263, 268, 269, 270 
Knaggs, 525 

Knapp, H.. 287, 298, 300, 356, 379, 403, 434, 438, 
519, 594, 633 
Knauer. 135 
Knies, 96, 733, 734 

Knipe. Jay C., chapter contributed by, 733 

Koch-Weeks bacillus, 252, 256, 268 

Kollmann. illustrations from, 3, 6 

Kollock, 319 

Konigshofer, 497 

Kostenitsch, 365 

Koster, 289, 380 


Kraemer, 478, 4S8 
Krahnstofer, 419 

Kp.all, John T., chapter contributed by, 686 
Krienes, 556 

Krischewski, illustration from, 6 
Kronlein’s operation, 652 
Kuchler, 343 

Kuhnt, 225, 278, 299, 447, 466 
Kunn, 199 

Kyanopsia. See Cyanopsia. 

Laceration of the sphincter of the iris, 394 
Lacrimal abscess, 226 
actinomycosis, 224 
apparatus, anatomy of, 22 
diseases of, 219 
operations on, 231 
blennorrhea of infants, 225 
bone, caries of, 224 
periostitis of, 224 
canaliculi, 23 
conjunctivitis, 277 
disease, etiology of, 224 
duct, anatomy of, 24 
obstruction of, 227 
stricture of, 227 
treatment of diseases of, 228 
fistula, 227 
gland, 22 
accessory, 22 
adenoma of, 220 
anatomy of, 22 
angioma of, 222 
atrophy of, 220 
carcinoma of, 222 
chloroma of, 221 
chondroma of, 222 
concretions in, 222 
cyst of, 221 
development of, 7 
dermoid cyst of, 222 
diseases of, 219 
dislocation of, 221 
excision of, 231 
palpebral portion, 231 
fistula of, 221 
hypertrophy of, 220 
inflammation of, 219 
lvmphadenoma of, 221 
myxoma of. 221 
palpebral, 22 
prolapse of, 221 
sarcoma of, 221 
syphilis of, 221 
tuberculosis of, 222 
tumors of, 221 
nerves, 31 
probes, 229, 235 
Bowman’s, 235 
Snellen's. 229, 235 
Theobald's, 229 
probing, 235 
puncta, 23 
affections of, 222 
sac, anatomy of, 23 
excision of, 234 
fistula of, 227 

inflammation of, 224, 225. 226 
obliteration of, 238 
syringing of, 233 

secretion, character of, in disease, 226 
Lacrimation in exophthalmic goitre, 644 
Lacrimo-nasal duct, 10 
Lagophthalmic keratitis, 317 
Lagophthalmos, 187 
Lagrange, 230, 503 
Lamina cribrosa, anatomy of, 32 
in glaucoma, 570, 571 
LANDOLT, 135. 115, 2S4, 672 
Lang, 374, 437, 612, 641 
Langenbeck, 641 
Lannelongue, 159 
Lantern tests for color-blindness, 130 
Laqueur, 507, 564 
Largin, 251, 255 

Latent deviation of ocular muscles, 675 
LAWFORD, 339, 538 
Lawson, A., 221 
Lawson, G., 415 

Le Fort’s method of skin-grafting, 216 



INDEX. 


809 


Lead acetate, 255 
encephalopathy, 508 

Leber, 35, 243, 284, 389, 419, 507, 508, 519, 523, 
555, 562, 603 
Lederer, 641 
Leeches in iritis, 392 
Lehmann, 509 
Lenhossek, 4 
Lens, 688 
biconvex, 63 
concave, 688 

conjugate focus of a convex, 689 
convex, 63 

conjugate foci of, 689 
crystalline. See Crystalline lens. 
cylindric, 690 
focal distance of a, 688 
focus of a concave, 690 
formation of images by a, 689 
optical centre of a, 688 
position of image formed by a convex, 690 
principal focus of a concave, 690 
of a convex, 688 
toric, 680 

Lenses, combination of, 691 
cylindric, 690 , 

numbering of, 690 
properties of optical, 686 
spheric, 688 
toric, 690 
Lenticonus, 438 
anterior, 438 
posterior, 438 
Lenticular ganglion, 17 
Lentiglobus, 438 

Leonard’s method of x-ray localization, 154 
Leopold, I., illustrations from—Pig. 1, Plate 
XIX, and Pig. 1, Plate XX. 

Leprosy of conjunctiva, 290 
of cornea, 341 
of eyelids, 174 
of iris, 380 
Leptomeningitis, 740 
Leptothrix in canaliculi, 223 
LERCHE, 484 

Leucocythemic retinitis, 503 
Leucoma, adherent, 350 
Leucosarcoma of chorioid, 486 
Leucosis, 412 

Levator palpebrae superioris muscle, 13 
contraction of, with pterygoid, 191 
LEVEILL£, 16, 17 
Lewin, 642 
LIEBREICH, 421, 505 
Ligamentum pectinatum, 31 
Light, definition of, 686 
perception of, 121 
-reflex of retinal blood-vessels, 58 
refraction of, 687 
-streak, 58 
waves of, 686 

Light-perception, qualitative, 121 
quantitative, 121 
Light-sense, testing of, 127 
in optic-nerve atrophy, 546 
subjective sensations of. See Photopsia. 
Lilienfeld, 576 
Limbus of cornea, 30 
Line of fixation, 68 
Linear extraction of cataract, 460 
method of measuring squint, 673 
Lipoma of eyelids, 168 
of orbit, 621 
subconjunctival, 240 
Lipomata cavernosa, 621 
telangiectodes, 621 
Lippincott, 371 
Lippitudo, 186 
Listing, law of, 73 
reduced eye of, 65 
Lithia-carmin, 781 
Lithiasis of conjunctiva, 276 
Liver, use of, in nyctalopia, 557 
Lloret, 300 

Localization of foreign bodies in the eye, 153 
Locomotor ataxia, 741 
Long ciliary arteries, 20 
Loring, E. G., 526 
ophthalmoscope of, 135 
Loring, F. B., 297 


Lupus of conjunctiva, 291 
of eyelids, 173 
vulgaris of eyelids, 173 
Luxation of crystalline lens, 439, 469 
of eyeball, 647 

Lymphadenoma of lacrimal gland, 221 
Lymphangioma of caruncle, 296 
of eyelids, 175 
of orbit, 623 

Lymphatics of eyelids, 28 
Lymph-channels of the cornea, 30 
of the eye, 55 
perivascular, 60 

-space, intervaginal, of optic nerve, 56 
perichorioidal, 56 
Lymphectasia of conjunctiva, 243 
menorrhagica, 243 
Lymphoma of conjunctiva, 275 
of eyelids, 175 
of iris, 380 

Macewen, 636, 637 
Mackenzie, 594 
Mackenzie, S., 489 
Macnamara, 519 
Macula corneas, 350 
lutea, Plate V, 42, 43, 46, 56, 60, 79 
halo around, 60 
“holes” in, 60, 522 
physiology of, 79 
symmetrical changes in, 512 
traumatic perforation of, 522 
vascularity of, 60 
Macular colobomata, 412 
keratitis, 333 

region, colloid disease of, 435 
Madarosis, 186 

Maddox, double prism of, 104 
rod test, 675 
Magendie, 316 
Magnani, 262 
Magnet, giant, 371 

Magnification of ophthalmoscopic image, 139 

Magnus, 492 

Malar bone, 8 

Malarial keratitis, 331 

Malherbe, 361 

Malignant pustule of eyelid, 162 
Malingering, 556 
tests for, 151 
Mandelstamm, 555 
Manifest hypermetropia, 697 
Manz, 5, 158, 537 

Manz-Ziegler, illustration from, 5 
Marchi, method of, 784 
Marginal phlyctenular keratitis, 320 
ulcerative keratitis, 337 
Marple, 496, 498 
Martin, W. A., 337 
Massage in retinal embolism, 497 
of cornea, 350 
of optic nerve, 548 
Maunther. 60, 552 
Mat, 135, 299 
Mayou, 284 
McQueen, 269 
McReynolds, 297 

Measurement of astigmatism, 117, 142, 149 
Measurements of the crystalline lens, 51 
of the eyeball, 29, 692 

Mechanical exercise in ocular paralyses, 668 
injuries of the cornea, 352 
Media, location of opacities in the trans¬ 
parent, 139 

Medullated fibres of optic nerve, 48 
“Medusa head” nerve, 534 
Megalocornea, 304, 345 
Megalophthalmos, 304 
Megalopsia, 500, 559 
Meibomian cysts. See Chalazion. 

glands, 26, 276 
Meibomius, glands of, 26 
Meigs, A. V., 415 
Melanin, 416 
Melanoma of iris, 376 
Melanosarcoma of chorioid, 419 
Melanosis of sclera, 361 
Mellinger, 315 
Membrana limitans externa, 43 
interna, 43 



810 


INDEX. 


Membrana vasculosa, 43 
Membrane of Demours, 31 
of Dgscemet, 31, 246 
Menard, 159 

Meningitis, cerebrospinal, 740 
following enucleation, 610 
tubercular, 740 
Meningocele, 618 
Meniscus, 688 

Mental blindness. See Mind-blindness and 
Psychic blindness. 

Mercury in iritis, 392 
in optic-nerve atrophy, 547 
Merkel, 11, 13, 49, 50, 55 
Merkel and Kallius, 20 
Metallic dots in the retina, 515 
foreign bodies in the eyeball, 370 
Metamorphopsia, 421, 559 
varians, 559 

Metastatic carcinoma of chorioid, 414 
sarcoma of chorioid, 415 
Method of inverted image. See Indirect oph¬ 
thalmoscopy. 

of upright image. See Direct ophthalmos¬ 
copy. 

Methyl alcohol, amblyopia from, 544 
Methylene blue, 791 
Metre angle, 123 

Metric system of numbering lenses, 690 

Meyer, 427, 603 

Meyer, P., 779 

Meynert’s fibres, 47, 739 

Mial, 231 

Microblepharon, 159 
Microphakia, 438 
Microphthalmos, 411 
Micropsia, 500, 501, 559 
Microsporon trachomatosum, 277 
Middle cervical ganglion, 19 
Migraine, 557, 743 
ophthalmic, of Charcot, 191 
Miliaria, 180 

Miliary aneurisms of retina, 429 
tubercle of chorioid, 412 
Military conjunctivitis, 276 
ophthalmia, 277 
Milium, 180 
Milles, 480 
Millikin, 418 
Mind-blindness, 739 
Miners’ nystagmus, 669 
Miosis, 96, 396, 734 
irritative, 96, 734 
paralytic, 96, 669, 734 
Miotics, 134 

Mirror, concave retinoscopy, 137 
ophthalmoscopic, 134, 136 
plane retinoscopy, 150 
Mittendorf, 467, 473 
Mitvalski, 414 
Mobility of the eye, 72 
of the iris, 96 
Mobius, 643 
Moll, glands of, 26 
Molluscum contagiosum, 172 
epitheliale, 172 
Monocular diplopia, 72 
Monoculus, 754 
Montgomery, 166 
Monzon, 378 
Moore, W. O., 503 
Mooren, 467, 515, 597, 598, 644 
ulcer of, 310 
Morax, 251, 252, 256 
Morgagni, spheres of, 442 
Morgagnian cataract, 442 
Morphin, 255 
Morton, 612 
Morvan’s disease, 744 
Motais, 199 

Motor disturbances of iris, 396 
Motor oculi nerve, 17 
Mounting of sections, 784 
Mucocele, 226 
of frontal sinus 634 
of inferior canaliculus, 223 
Mucoid degeneration, demonstration of, 7S8 
Mules, 198, 596, 611 
method of evisceration, 611 
advantages of, 613 


Mules’s operation for ptosis, 198 
Muller, fibres of, 4-t 
muscle of, 12 

Muller, L., operation for ectropion, 210 
Muller’s fluid, 774, 775 
Multiple neuritis, 742 
sclerosis, 740 

Muse® volitantes, 70. 475, 476 
Muscle, ciliary, 36, 37 
obliaue inferior, 15 
superior, 13 
of Horner, 24 
of Muller, 12 
of Riolan, 26 
rectus externus, 14 
inferior, 15 
internus, 14 
superior, 13 

Muscles, action of the, 654 
Muscular asthenopia, 679 
insufficiency. See Heterophoria. 
tissue of the iris, 33 
Muttermilch, 277 
Mycotic keratitis, 331 
Mydriasis, 396, 734 
paralytic, 668, 735 
Mydriatics, 131 
in iritis, 382, 391 
Myelitis, 732 
Myoma of chorioid, 420 
Myopia. 703 
acquired, 709 
angle gamma in, 713 
atrophic changes in, 425 
axial, 367, 704 

chorioidal changes in, 425, 712, 714 

congenital, 706 

conus in, 710 

correction of, 716 

curvature, 705 

definition of, 703 

detachment of retina in, 710 

diagnosis of, 714 

etiology, 704 

heredity in, 706 

in school-children, 707 

influence of muscles in producing, 706 

ophthalmoscopic appearance in, 714 

ordering glasses for, 715, 716 

pathologic evolution of, 768 

pathology of, 710 

prevalence of, in public schools, 767 

prisms in, 716 

reading glasses in, 716 

removal of crystalline lens in, 716 

retinal hemorrhages in, 714 

skiascopy in, 148 

symptoms of, 712 

tenotomy of external rectus in, 716 
theories of causation of, 705 
transient, in iritis, 393 
treatment of, 714 

Weiss’s reflex in. Fig. 2, Plate XX, 714 
with glaucoma, 571 
Myopic astigmatism, 719 
chorioiditis, 425 
crescent. See Conus. 
degeneration, 426 
Myosis. See Miosis. 

Myxoma of conjunctiva, 241 
of cornea, 304 
of lacrimal gland, 221 

Nsevus pigmentosus, 170 
vasculosis of eyelid, 175 
Nagel, 502 
Nasal artery, 21 
duct, anatomy of, 10, 24 
diameter of, 24 
obstruction of. 227 
stricture of, 227 

Naso-lacrimal canal, operations on the, 233 
NatansON, 262 
Near point, 68 

determination of. 122 
of convergence, 123 
-sight. See Myopia. 

Nebula, 350 
Necrosis of orbit, 627 

Needle operation for cataract. See Discission. 






INDEX. 


811 


Negative convergence, 123 
Neisser, 262, 264 
Nephritis, retinitis in, 505 
Nerve, optic. See Optic nerve. 

ophthalmic. See Ophthalmic nerve. 

Nerves, corneal, 31 
iridal, 35 
palpebral, 28 

Nervous diseases, ocular manifestations of, 

733 

Nesnamoff, 283 

Nettleship, E., 427, 435, 504, 516, 773 
Neuralgia, 743 
Neurasthenia, 745 
Neurasthenic asthenopia, 526 
Neurectomy, opticociliary, 561 
Neuritic dots in the retina, 515 
Neuritis, descending, 536 
optic. See Optic neuritis. 
retrobulbar. See Retrobulbar neuritis. 
Neuroepithelioma of the retina, 418 
diagnosis of, 484 
etiology of, 483 
pathology of, 4S2 
prognosis of, 487 
symptoms of, 484 
treatment of, 488 
Neuroepithelium, 46 
Neurofibroma of eyelid, 175 
Neuroma of eyelid, plexiform, 175 
Neurons of the retina, 43 
Neuroparalytic keratitis, 316 
Neuropathic keratitis, 316 
Neuroretinitis, 387, 534, 535 
Neurosis following traumatism. 745 
Neurotomy, opticociliary, 561, 604 
Neustatter, 558 
Neve, 290, 341, 380 
Nevus of iris, 380 
Nicati, 407 
Nieden, 317, 641 
Night-blindness, 556 
Nitrate of silver, 254, 257, 259, 266, 270 
Nitrobenzol, amblyopia from, 542 
Nitroglycerin in optic-nerve atrophy, 548 
Nodal point, 62 
Nodular keratitis, 333 
Noma of the eyelids, 179 

Non-gonorrheal purulent conjunctivitis, 268 
Non-magnetic foreign bodies. 373 
Non-suppurative keratitis, 320 
Nordexsex. 508, 523 
Normal fundus oculi, Plate III 
intra-ocular tension, 562 
Norris and Oliver, 399 
Notched teeth, 323 

NOYES. H. D., 221, 224, 300, 361, 578, 585, 594 
Nuclear palsy, acute, 665 
chronic, 666 
stains, 779 

Nuclei of ocular nerves, 49 
Nucleus of abducens nerve, 51 
of crystalline lens, 52 
of oculomotor nerve, 50 
of patheticus nerve, 51 
NUEL. 326, 329, 334, 369, 562 
stitch for scleral rupture, 369 
Numbering of lenses, 690 
Nummular keratitis, 333 
Nussbaum, 360 
Nyctalopia, 556 
Nystagmus, 669, 734 
acquired, 669 
congenital, 669 
miners’, 669 
treatment of, 669 

Oatman, 414 .... 

Oblique illumination. See Focal illumination. 
muscles, anatomy of, 13, 15 
insufficiency of. 677 
paralysis of. 662 
tests for, 677 

Occlusion of the pupil, 387 
Ocular ataxia, 741 
lymph-spaces, 55 

manifestations of nervous diseases. 733 
movements and binocular vision. 72 
muscles, abnormal balance of. See Hetero- 
phoria. 


Ocular muscles, absence of, 618, 733 
action of, 73 
advancement of. 684 
associated paralyses of, 664, 733 
balance of, 101 
congenital defects of, 618 
insufficiency of. See Heterophoria. 
operations upon the, 681 
paralysis of external. See Ophthalmo¬ 
plegia. 

physiology of, 72 
spasm of, 734 
tests for balance of, 102 
Oculomotor nerve, paralysis of, 663 
radiations of, 50 

Oculo-orbital fascia, anatomy of, 11 
inflammation of, 632 
Oettingen, 287 
Ogilvie, 522 

Oliver, C. A., 242, 489, 578, 579, 580, 605, 612 
Onyx, 307 

Opacities in cornea, 350 
in crystalline lens. See Cataract. 
in vitreous humor, 475 

Opaque nerve-fibres in the retina, 481; Fig. 

2, Plate IV. 

Operating mask, 749 
Operation room, 755 
Operations, for cicatricial orbit, 615 
for glaucoma, 584 
for muscular insufficiency, 681 
for post-operative cataract, 465 
for traumatic cataract, 464 
on the conjunctiva, 296 
on the cornea, 355 
on the crystalline lens, 449 
on the eyelids. 195 
on the iris, 397 
on the optic nerve, 560 
on the orbit, 651 
on the lacrimal apparatus, 231 
on the retina, 525 
on the sclera, 590, 591 
on the sympathetic nerve, 586 
preparation for, 749 
Ophthalmia. See Conjunctivitis. 
gonorrheal, of adult, 263 
migratoria, 594 
neonatorum, 262 
nodosa. 285 
tarsi, 185 

Ophthalmic artery, aneurism of, 639 
migraine, 191 
vein, anatomy of. 21, 22 ' 
thrombosis of, 636 

Ophthalmitis, sympathetic. See Sympathetic 
inflammation. 

Ophthalmoblennorrhea, 262, 267 
Ophthalmomalacia. 436 
Ophthalmometer, description of, 116 
Kagenaar's model of, 117 
of Helmholtz, 116 
of Javal-Schioetz, 118 
use of, 116 

Ophthalmometry, 115 
Ophthalmophantome, 749 
Ophthalmoplegia, 665 
acute, 665 
chronic, 666 
external, 666 
internal. 666 
total. 666 

Ophthalmoscope as a refractometer, 141 
description of. 134 
direct method of using, 13S 
formation of image in direct method of 
using, 137 

in indirect method of using, 137 
indirect method of using the, 138 
magnifying power of the, 139 
methods of use, 135 
of Couper, 135 
of Harlan, 135 
of Helmholtz, 134 
of Jackson, 135 
of Knapp, 135 
of Knauer, 135 
of Landolt, 135 
of Loring, 135 
of May, 135 





812 


INDEX. 


Ophthalmoscope of Morton, 135 
of Pyle, 135 
of Randall, 135 
of Snell, 135 
of Thorner, 134 
use of the, 139 
Ophthalmoscopy, 134 
direct, 137 
indirect, 137 
Optic axis, 62 

Optic canal, fracture of, 649 
Optic chiasma, 47 
Optic commissure, 47 
Optic disc, 57 

Optic nerve, absence of, 528 
anatomy of, 41 
anomalies of, 528 
aplasia of, 528 
apoplexy of, 549 
atrophy of. 545 
causes of, 546 
congenital, 528 
diagnosis of, 547 
etiology of, 546 
hereditary, 548 

ophthalmoscopic changes in, 546 
pathology of, 547 
primary, 545 
prognosis of, 547 
retinal type of, 546 
secondary, 545 
symptoms of, 545 
treatment of, 547 
visual field in, 545 
colloid bodies in head of the, 532 
coloboma of sheath of, 528 
congenital defects of, 528, 529 
crossing of fibres of, 47 
development of, 5 
diseases of, 528-561 
drusenbildungen in, 532 
edema of head of, 536, 569 
embolic atrophy of, 546 
excavation of, in atrophy, 546 
in glaucoma, 570 
physiologic, 57 
extradural tumors of, 531 
hemorrhage into sheath of, 549 
hereditary atrophy of, 548 
hyalin bodies in head of, 532 
hyperemia of, 534 
injuries of, 560 
intervaginal space of, 48 
intracranial part of, 41 
intradural tumors of, 530 
lymph-channels of, 48 
number of fibres in, 48 
opaque fibres of, 481 
operations on, 560 
orbital portion of, 48 
pallor of temporal segment of, 542 
physiologic excavation of, 57 
pigmentation of head of, 529 
primary atrophy of, 545 
radiations of, 49 
resection of, 560 
retinal type of atrophy, 546 
secondary atrophy of, 545 
sheaths of, anatomy of, 48 
dilation of, 536 
tumors of, 530 
Optic neuritis, 533 

after orbital affections, 631, 636, 638, 646, 
649 

albuminuric, 506 

back-water theory of, 536 

course and complications of, 536 

descending, 534 

diagnosis of, 535 

etiology of, 535 

forms of, 534 

from brain tumor, 536 

from general diseases, 535 

hemorrhages in, 534 

inflammatory theory of, 537 

intra-ocular, 533 

lymph-space theory of, 537 

mechanism of, 536 

monocular, 535 

orbital, 539 


Optic neuritis, Parinaud’s theory of, 538 
pathogenesis of, 536 
pathology of, 536 
prognosis of, 536 
retrobular, 539 
acute, 539 
causes of, 539 
chronic, 541 
diagnosis of, 540 
pathology of, 540 
prognosis of, 540 
symptoms of, 540 
treatment of, 540 
toxic, causes of, 542 
ophthalmoscopic picture in, 542 
second attacks of, 536 
Sourdille’s theory of, 538 
spurious, 541 

surgical treatment of, 539 
sympathetic, 601 
symptoms of, 533 
syphilitic, 536 
treatment of, 539 
types of, 534 

vasomotor theory of, 538 
with dropping of fluid from nose, 541 
Optic radiations, 49 
Optic tract, 535 
Optical axis, length of, 29, 692 
Optical centre of lens, 688 
Optical defects of normal eye, 6S 
Optical lenses, properties of, 686 
Opticociliary neurectomy, 560 
neurotomy, 560 
Optograms, 80 
Ora serrata, 42 
Orange G, 782 

Orbicularis, paralysis of. See Lanophlhalmos. 
pupillary reaction. See Gifford’s reflex. 
spasm of, 189, 734 
Orbit, abscess of, 610, 627, 631 
anatomy of, 8 

aneurism by anastomosis in, 639 
angioma of, 621 
axis of, 8 
blood-cyst of, 626 
-vessels of, 20 
bony tumors of, 624 
capillary angiomata of, 621 
carcinoma of, 625 
caries of, 627 

cavernous angiomata of, 621 
cellulitis of, 630 

cerebral symptoms following injury of, 649 

chondroma of, 623 

congenital anomalies of, 616 

congenital cyst of, 618 

contusion of, 646 

cysts of, 618, 625 

dermoid cyst of, 619 

diseases of, 616-653 

distension of cavities adjacent to, 633 
echinococcic cyst of, 626 
emphysema of, 648 
enchondroma of, 623 
endothelial tumors of, 625 
enophthalmos, 640 
epithelial tumors of, 625 
examination of, 100 
exenteration of, 653 
exostoses of, 630 

extirpation of whole contents of, 652 
extravasation cyst of, 626 
exudation cysts of, 625 
fistula of, 627 
follicular cysts of, 626 
foreign bodies in, 650 
fracture of, 648 
of apex of, 649 
gummata of, 629 
hematoma of, 626 
hemorrhage into, 637 
hydatid cyst of, 626 
hyperostosis of, 630 

inflammation of oculo-orbital fascia, 632 
of sinuses adjacent to, 633 
injuries of, 646 

intermittent exophthalmos, 640 
lipoma of, 621 
lymphangioma of, 623 



INDEX. 


813 


Orbit, necrosis of, 627 
nevus of, 621 
operations on, 651 
osteoma of, 624 
parasitic cysts of, 626 
penetrating wounds of, 646 
periostitis of, 627 
periostosis of, 629 
phlegmon of, 630 
plexiform angiomata of, 621 
neuroma of, 625 
pulsating exophthalmos, 638 
removal of tumors of, 651 
by Kronlein’s operation, 652 
retention cysts of, 626 
sarcoma of, 624 
shape of, in myopia, 713 
tumors of, 618 
etiology of, 619 
prognosis of, 620 
symptoms of, 620 
treatment of, 620 
varieties of, 621 
vascular tumors of, 621 
wounds and injuries of, 646 
Orbital cellulitis, 630 
deep incisions in, 632 
effects of, on vision, 632 
following tenotomy, 682 
prognosis of, 631 
treatment of, 632 
Organic entropion, 280 
Orth, 781 
Orthophoria, 670 

Orthoptic exercises in heterophoria, 680 
training in strabismus, 674 
Ossification of chorioid, 420 
Osteoma of conjunctiva, 242 
of orbit, 624 
OSTWALT, 432 
O'Sullivan, 527 
Ozena bacillus, 225 

Pachymeningitis. 508 
Pagenstecher, 199, 305, 460, 599 
Pagenstecher’s salve. See Yellow oxicl of mer¬ 
cury. 

oneration for ptosis, 199 
Palpebral ligaments, 26 
Panas, 197, 245, 305, 357. 471, 681 
operation for ptosis, 199 
Pannus, 325 
crassus, 326 
eczematosus, 320 
granular, 328 
jequirity in, 329 
sarcomatosus, 326 
tenuis, 326 
treatment of, 328 
Panophthalmitis, 264 
ectoerenous, 430 
diagnosis of, 432 
nathology of, 431 
prognosis of, 432 
svmptoms of, 431 
treatment of, 432 
endogenous, 429 
diagnosis of, 430 
prognosis of. 430 
symptoms of, 430 
treatment of, 430 
enucleation during, 433 
evisceration during, 433 
meningitis from, 433 
Papilla. See Optic nerve. 

Papillitis (see also Optic neuritis), 533 
Papilloma of conjunctiva, 241 
of cornea, 304 

Papilloretinitis, sympathetic, 601 
Papular conjunctivitis. 275 
Paquelin cautery, 623 
Paracentesis cornese, 355 
in corneal ulcer, 315 
in iritis, 392 
of cornea, 355 
Paradoxic pupil, 743 
Paraffin-imbedding, 777 
injections, danger of, 207 
Parallax test. 143 
for heterophoria, 676 


Parallax test in glaucoma, 571 
Paralysis agitans, 743 
bulbar, 645, 742 
of accommodation, 669 
of external rectus, 661 
of inferior oblique, 662 
of internal rectus, 661, 662 
of ocular muscles, 657 
cerebral, 664 

clinical method of determination, 663 
cortical, 664 
diagnosis of, 661 

diagrams illustrating, 658, 659, 660, 661, 665 
diplopia in, 657 
etiology of, 664 
false muscular projection, 659 
fascicular, 664 
general symptoms of, 657 
limitations of movements of globe, 658 
nuclear, 664 
orbital lesions in, 667 
peripheral, 666 
position of head in, 659 
primary deviation in, 657 
prognosis in, 668 
projection of false image, 657 
recurrent third-nerve, 667 
secondary deviation in, 657 
special symptomatology 6f, 661 
treatment of, 668 
of oculomotor nerve, 663 
of superior oblique, 662 
of superior rectus, 662 
of third nerve, 667, 734 
pseudobulbar, 742 
Paralytic miosis, 669 
mydriasis, 668 

Parasitic skin diseases, 182 
Parenchymatous iritis, 385 
Parenchymatous retinitis, 502 
Paresis of accommodation, 669 
Parinaud, 199, 251, 275, 538 
conjunctivitis of, 275 
Passler, 642 
Patheticus nerve, 18 
radiations of, 51 
! Patne, R. W., 437 
Pearl-cysts of iris, 378 
Pectinate ligament, 40 
Pegged teeth, 323 
Pemphigus, 165 
of conjunctiva, 275 
of cornea, 329 
of eyelids, 165 
Periectomy, 301 
Perifolliculitis, 166 
Perimeter, 124 
Dana’s, 125 
McHardy’s, 125 
Skeel’s, 125 
Smith’s, 125 
Perimetry, 124, 125 
Periostitis of orbit, 627 
Periostosis of orbit, 629 

Peripheral paralysis of ocular muscles, 666 
Peritomy, 301 

Perivascular lymph-channels, 60 

Perl’s reaction, 790 

Persistent pupillary membrane, 374 

Petit, 312 

Pfitzner, 781 

Pfeiffer, 277 

Pflange, 519 

Pfluger, 345 

Phagedenic ulceration of eyelids, 179 
Phlebosclerosis, 511 
Phlegmon of lid, 162 
Phloroglucin method, 776 
Phlvctenula pallida, 260 
Pnlyctenular conjunctivitis, 272 
keratitis, 320 
ophthalmia, 272 
pannus, 328 
ulcer, 320 

Phosphoridrosis, 179 
Photophobia, 247 
Photopsiae, 421 
Phtheiriasis, 182 
Phthisis bulbi, 264, 436 
Physiologic excavation, 57 




814 


INDEX. 


Physiology of vision, 62 
Pian, 161 

Picric acid, 776, 782 
Pigment patches in conjunctiva, 2S0 
on optic disc, 529 
streaks on the fundus, 518 
Pigmentary degeneration of the retina, 519 
Pigmentation of conjunctiva, 280 
Pigmented retina and chorioiditis, 519 
Pilocarpin, 576 
in glaucoma, 576 

Pince-ciseaux of de Wecker, 401, 402, 403 
Pincus, 304 
Pinguecula, 287 
“Pink eye,” 252, 254 
Placido’S disc, 93, 344 
Plastic chorioiditis, 420 
cyclitis, 408 
iritis. 384 

Plexiform neuroma of eyelid, 175 
Plica semilunaris, 25 
affections of, 295 
Pneumococcus, 252, 269 
conjunctivitis, 252 
in corneal ulcers, 309, 312 
Pollock, illustration from, 403 
Polycoria, 375 
Polypi of conjunctiva, 241 
Porter, W. H., 505 
Posey, 489 
Post, M. H., 418 
Posterior polar cataract, 426 
sclerochorioiditis, 425 
sclerotomy, 593 
synechiae, 387 
staphyloma, 425, 711 
svmblepharon, 280 
Postero-lateral sclerosis, 742 
Post-iritic glaucoma, 387 
Post-operative cataract, 446 
operations for, 465 
Poultices, 251 
Powers, 462 
Praun, 368 
Pregnancy kidney, 510 

Prentice’s method of numbering prisms, 6S8 
Presbyopia, 725 
definition of, 725 
diagnosis of, 728 
etiology of, 725 
selection of glasses, 728 
symptoms of, 726 
treatment of, 728 
Pretended amblyopia, 556 
Primary deviation, 657 
opacity of the cornea, 334 
Principal anterior focus, 63 
• axis, 688 

focal distance, 688 
posterior focus, 62 
Prism, angle of deviation of a, 687 
convergence, 108 
Cretes’s, 107 
dioptre, 688 
divergence, 109 
holders, 109 
Maddox’s double, 104 
refracting angle of a, 688 
Risley’s, 107 
rotary, 107 

-tests for heterophoria, 103, 104, 105, 106, 1C7 
for strabismus, 673 
Prisms, exercises with, 680 
numbering of, 688 
prescription of, in heterophoria, 680 
in myopia, 716 
Probe, Bowman’s, 235 
Caldwell’s lacrimal, 237 
false passage by a, 236 
Snellen’s, 229, 235 
Theobald’s, 229 
Probing of nasal duct, 235 
Projection of false image, 657 
Prolaose of iris, 395, 454 
of vitreous humor, 452 
Prosthesis, ocular, 613 
Protargol, 251, 255, 257, 290 
Protoplasmic stains, 782 
Protrusion of globe, 74 
Pseudobulbar paralysis, 742 


Pseudo-glioma, 480 
Pseudo-neuroepithelioma, 480 
Pseudopterygium, 287 
Psorophthalmia, 185 
Pterygium, 285 

actual cautery in treatment of, 297 

cicatricial, 287 

congenital, 239 

crassum, 285 

etiology of, 286 

excis.on of, 297 

McReynolds’s operation for, 297 
operations for, 297 
pathology of, 2S6 
prognosis of, 286 
tenue, 285 

transplantation of, 297 
treatment of, 286 
Ptosis. 191, 733 
adiposa, 196 
congenital, 159 
operations for, 196 
spurious, 191 
treatment of, 191 
unilateral, 191 

Pulsating exophthalmos, 638 
Pulsation of retinal arteries, 573 
vessels in glaucoma, 572, 573 
Puncta lacrimalia, acquired anomalies of, 222 
Punctate conditions of the fundus, 481 
proximum. See Near point. 
remotum. See Far point. 

Pupil, Argyll Robertson, 97 
contraction of, 71 
from irritation, 96 
from paralysis, 96 
dilation of, 71 
paralytic, 71 
spastic, 71 
examination of, 95 
Gifford-Galassi reflex of, 98 
Haab’s reflex of, 98 
measurement of, 96 
occlusion of, 387 
Robertson, 97 
skin-reflex of, 98 
Wernicke’s inaction of, 97 
Westphal-Piltz reflex of, 9S 
Pupillary area, examination of, 98 
reaction, facts concerning, 97 
Pupillometer, 96 
Purkinje-Sanson images, 67 
Purulent chorioiditis, 429 
conjunctivitis, 262 
cyclitis, 409 
ophthalmia, 262 
Pusey, B., 379 
Pustular conjunctivitis, 254 
Pyle, 135, 468 
Pyoktanin, 227 

Quaglino, 361,. 591 
Quenu, 584 

Quincke’s reaction, 790 
Quinin-amaurosis, 543 

Rabl, 4 
Radian, 688 

Raehlmann, 225, 281, 326, 345, 523 
Ramsay, 188, 191, 323, 615 
Randall, 135 

Randolph, R. L., 239, 262, 471, 601 
Raupenhaar-ophthalmie, 285 
Recklinghausen, 338 
RfeCLUS, 584 

Rectus, external. See External reetus. 
Recurrent third-nerve paralysis, 667 
Red-blindness, 550 
Reduced eye of Listing, 65 
Refraction, 62 
errors of, 686 
Reik, H. O., 438 
Reisinger, 360 

Relapsing herpes of the cornea, 333 
Relative ocular movements. 74 
Renal vascular retinitis, 505 
Renversement of a corneal flap, 358 
Retina, anatomy of, 42 
anemia of, 489 



INDEX. 


815 


Retina, anesthesia of, 526 
aneurism of vessels of, 492 
angioid streaks in, 518 
apoplexy of, 492 
cerebral layers of, 44 
ciliary and iridal parts of, 46 
coloboma of, 481 
concussion of, 521 
congenital anomalies of, 481 
cysts of, 482 
detachment of, 416, 522 
diagnosis of, 524 
etiology of, 522 
pathology of, 523 
prognosis of, 524 
symptoms of, 523 
treatment of, 525 
development of, 6 
diseases of, 481-527 
edematous swelling of, 521 
embolism of central artery of, 494 
diagnosis of, 497 
etiology of, 496 
pathology of, 496 
symptoms of, 495 
treatment of, 497 
functional diseases of, 526 
functions of, 77 
glioma of, 482 
hemorrhages in, 492 
hyperemia of, 489 
active, 490 
passive, 490 
hyperesthesia of, 526 
inflammation of, 500 
irritation of, 526 
ischemia of. 489 
layers of, 43 

light-streak of vessels of, 58 
neuroepithelial layer of, 46 
neuroepithelioma of, 418, 482 
opaque nerve-fibres in, 481 
optic part of, 43 

pigmentary degeneration of, 519 
pseudo-neuroepithelioma of, 487 
pulsation of vessels of, 58, 569, 572, 573 
punctate conditions of, 515 
Purkinje’s phantom image of vessels of, 79 
rupture of, 521 

subhyaloid hemorrhage of, 494 
traumatic anesthesia of, 522 
edema of, 521 

perforations of macula of, 522 
tuberculosis of, 527 
Retinal artery, embolism of, 494 
thrombosis of, 498 
hemorrhage, 521 
image, demonstration of, 65 
formation of, 64 
size of, 66 

pigmentation, variations in, 4S1 
vasculitis, 490 
vein, thrombosis of, 498 
vessels, sclerosis of, 490 
Retinitis, albuminuric, 505 
diagnosis of, 508 
etiology of, 505 

induction of premature labor in, 510, 511 
of pregnancy, 509 
pathology of, 506 
prognosis in, 509 
statistics of, 505 
symptoms of, 506 
treatment of, 511 
Bright’s, 505 
circinata, 513 
diabetic, 503 

central punctate, 503, 504 
embolic, 516 
from concussion, 500 
from excessive light, 514 
glycosuric, 503 
gouty. 511 

gravidarum, 505, 510 
hemorrhagic, 492 
hyperplastic proliferating, 517 
leucocythemic, 503 
nyctalopic, 500 
parenchymatous, 502 
pigmentosa, 510 


Retinitis pigmentosa, diagnosis of, 520 
etiology of, 519 
ophthalmoscopic signs of, 519 
pathology of, 520 
prognosis of, 520 
symptoms of, 519 
treatment of, 521 
proliferans, 480, 517 
proliferating, 517 
punctata albescens, 515 
purulent, 516 
metastatic, 516 
traumatic, 516 
renal vascular, 505 
saturnine, 508 
septic, 517 
serous, 500 
simple, 500 
solar, 514 
specific, 501 
striata, 518 
syphilitic, 500, 501 
prognosis in, 502 
treatment of, 502 
traumatic, 521 
Retinoscopy, 145-151 
Retraction of the globe, 74 
Retrobulbar optic neuritis, 539 
Retrotarsal folds, removal of, 299 
Reverdin, 213 
Reversal of color-fields, 527 
Reymond, 315 
Rhagades, 161 

Ribbon-shaped corneal opacity, 334 
Richey, 578 
Richter, 460 
Ridley, 277 

Ring ulcer of cornea, 310 
RlSLEY, 107, 459, 578 
Rivers, 515 

Robertson, Argyll, operation for ectro¬ 
pion, 208, 209 
symptom, 97, 741 
Rodent ulcer of cornea, 310 
of eyelids, 176, 177 
Rods and cones in vision, 79 
Roemer, 433 

Roentgen rays. See X-rays. 

Rogman, 361 

Rosenbach's phenomenon, 644 

Rosenstein, 509 

Roser, 311 

Rotary prism, 79 

Roth, 516, 517 

Round central ulcer of cornea, 310 
Rubeola, 184 
Rumschewitz, 305 
Rupture of chorioid, 184 
Schlemm’s canal, 369 
Russell. 513 
Rydel, 522 

Sachs, 498, 512 

Saemisch, 311, 315, 316, 357, 361 
incision in hypopyon keratitis, 315, 357 
Saenger, 642, 643, 644 
Safranin, 781 

Salicylate of sodium in phlyctenular con¬ 
junctivitis, 274 

in sympathetic ophthalmitis, 605 
“Salmon patches,” 323 
Salzer, 222 

Santorini, emissary vein of, 636 
Sarcoma of caruncle. 296 
of chorioid, 415 
of ciliary body, 405 
of conjunctiva, 244 
of cornea, 305 
of eyelid, 177 
of iris, 378 

of lacrimal gland. 221 
of optic nerve, 531 
of orbit, 624 
Sattler, 277, 281, 289 
Saturnine retinitis, 508 

Savage’s orthoptic exercises in heterophoria, 
681 

Scarlatina, 184 
Scarpa, 367, 368 
Schapringer, 641 





81G 


INDEX. 


SCHEFFELS, 502 
Scheiner’s experiment, 72 
Schieck, 305 
Schiele, 283 
Schiess, 437 

Schirmer, 365, 456, 594, 596, 598, 599, 601 
Schlemm’s canal, 41 
rupture of, 369 
SCHLESINGER, 506 
Schmidt, A., 220 
Schmidt-Rimpler, 603 
Schnabel, 425 
Schobl, 495, 503, 504, 518, 524 
Schoen, 67 
SCHREIBER, 276 
SCHROEDER, 224 
Schwalbe, 41 
Schweigger, 306, 461, 580 
Sclera, anatomy of, 32 
congenital anomalies of, 361 
diseases of, 361 
ectasias of, 366 
examination of, 92 
foreign bodies in, 370 
in fundus picture, 61 
injuries of, 368 
treatment of, 369 
melanosis of, 361 
operations upon, 373 
osteoma of, 361 
perforating wounds of, 368 
perforation of, during tenotomy, 682 
pigmentation of, 361 
protrusions of, 366 
rupture of, 368, 369 
telangiectasis of, 361 
tumors of, 361 
wounds of, 368 

Scleral puncture in detachment of retina, 525 
staphvlomata, 366 

wounds, infected, cauterization in, 370 
Scleritis. 364 
deep, 364 
superficial, 361 
treatment of, 366 
Sclerocyclocotomy, 590 
Sclerokerato-iritis, 364 
Scleronyxis, 462 
Sclero-optic neurectomy, 611 
Sclerosing keratitis, 364 
Sclerosis of corneal limbus, 340 
Sclerotic, large paracentesis of, 590 
Sclerotica. See Sclera. 

Sclerotomy, 591 
anterior, 591 

in detachment of retina, 525 
in glaucoma, 591 
posterior, 593 
Scopolamin, 132 
Scotoma, central, 126 
false, 126 
negative, 126 
positive, 126 
scintillans, 557 
true, 126 
Scott, 226 

Scrofulous keratitis, 320 
ophthalmia, 272 
Seabrook, 283 
Seborrhea, 180, 185 
of eyelids, 180 
of palpebral margins, 185 
Second principal focus, 62 
“Second sight,” 440 
Secondary deviation, 657 
eversion of eyelid, 89 
eye-cup and eye-membranes, 4 
positions of eyes, 73 
Secondi, 315 
Seebeck, 128 
Seeley, 351 
Senile iritis, 389 
Senn, 618 

Serous cyclitis, 333, 388, 406 
iritis, 333, 384 

Serpiginous syphilide of eyelids, 173 
ulcer of cornea, 311 
Sesemann, 536 
Shadow test, 145-151 
Sharkey. 643 


Sherer, 544 

Shoemaker, W. T., chapter contributed by, 
616 

Shumway, 487 
Sich-el, 525 
Siderophone, 157 
Sideroscope, 153 
Siderosis of conjunctiva, 290 
of cornea, 341 
of evelids, 167 
SlEGRIST, 498 
Silcock. 419 

SlLEX, 239, 305, 507, 509, 510 
SlLVESTRI, 307 
Simon, R., 305 
Simple conjunctivitis, 251 
granular conjunctivitis, 257 
hvnertrophy of lacrimal gland, 220 
keratomalacia, 318 
optical system, 62 
ulcer of the cornea, 310 
Simulated amblyopia, 556 
blindness, tests for, 151 
Sinus, cavernous, thrombosis of, 636 
Sinuses, affections of, 633 
Sixth nerve, 19 
radiations of, 51 
Skiascopy, 145 
in astigmatism, 149 
in emmetropia, 147 
in hypermetropia, 147 
in myopia, 147, 149 
with concave mirror, 147 
with plane mirror, 150 
Skin diseases of eyelids, 160 
Skin-grafting, Reverdin’s method of, 217 
Thiersch’s method of, 217 
without a pedicle, 216 
Skin-transplantation. See Dlepharoplasty. 
Small-pox. See Variola. 

Smith, Eugene, 341, 394, 400, 459, 460 
Smith, Priestley, 51, 93, 113, 125, 497, 562, 
663, 773 

Snell, A. C., 378 
Snell, S., 135, 242 

Snellen, 119, 120, 151, 199, 203, 204, 207, 235, 
304, 316, 345, 583 
operation for ectropion, 207 
for entropion, 203 
test-types of, 119 
Snow-blindness, 514 
Solid edema of eyelids, 169 
Solitary tubercle of chorioid, 41S 
Sourdille, 269, 538 
Spasm of accommodation, 697 
of ocular muscles, 669 
of orbicularis, 189 
Spastic ectropion, 280, 457 
enophthalmos, 640 
strabismus, 669 
Specific keratitis, 321 
Spectacles, care of, 771 
Spectral colors, 128 
Sphenoidal fissure, 9 
sinus, diseases of, 633 
Spheric aberration, 69 
lenses, 688 

Sphincter of the iris, 34 
Spbincterectomy, 399 

Spongy exudation into anterior chamber, 457 
Spongy iritis, 385 

Spontaneous gangrene of eyelids, 179 
Spontaneous rupture of eyeball, 418 
Spring conjunctivitis, 260 
Spurious optic neuritis, 530, 541 
Squint. See Strabismus. 

Staining eye sections, 779 
Standtsh, Myles, 268 
Staphylectomy, 356 
Staphylococci in corneal ulcers, 309 
Staphyloma, 306, 309 
anterior, 341 

congenital, of cornea, 304 
of cornea, 306, 309, 341 
treatment of, 343 
of sclera, 366 
treatment of, 368 
operations for, 356 
pellucidum, 341 
posterior, 367, 425, 711 



INDEX. 


817 


Starkle, 525 
Stauungspapille, 533 
Steatoma, 180 
Steiner, 280 
Stellwag, 216, 304 
sign in exophthalmic goitre, 643 
Stenopeic slit, 721 
spectacles, 345 

Stephenson 225, 255, 257, 258, 281, 284, 290, 
oUU, oZi, 521 
Stereoscope, 674 
Stereoscopic tests, 152 
vision, 76 

Sterilization of dressings, 754 
of instruments, 753 
Sternberg, 251 

Stevens s classification of heterophorias, 101 
clmoscope, 112 
method of tenotomy, 683 
phorometer, 107 
tropometer, 110 
Stieren, 406 
Stilling, 234 
Stillson, 525 
Stirling, 578 
Stolting, 583 
Story, 527, 605 
Strabismometer, 115 
Strabismometry, 112 
Strabismus, 670 
alternating, 671 
amblyopia in, 671 
angle of, 672 

angular method of measurement of, 672 
comitant convergent, 671 
divergent, 671 
convergent, 671 
causes of, 671 

educative treatment of, 674 
in hypermetropia, 698 
occlusion of fixing eye in, 674 
operative treatment of, 675 
orthoptic training of, 674 
spectacle treatment of, 673 
tenotomy in, 675 
treatment of, 674 
results of tenotomy in, 675 
deorsumvergent, 670 
divergent, 670 
concomitant, 671 
causes of, 672 
operations for, 681 
tenotomy in, 675 
treatment of, 673 
etiology of, 671 
in myopia, 714 
latent. See Heterophoria. 
measurement of, 112, 672 
monocular, 671 

operative correction of, 675, 6S1 
orthoptic treatment of, 674 
paralytic, 657 

diagnosis of affected eye in, 661 

diplopia in, 657 

etiology of, 664 

field of fixation in, 658 

from injury, 667 

general symptoms of, 657 

method of examination of eye in, 663 

of basal origin, 667 

of central origin, 664 

of nuclear origin, 665 

of peripheral origin, 664 

orbital, 667 

position of false image, 657 
of head in, 659 
primary deviation in, 657 
prognosis of, 668 
secondary deviation in, 657 
special symptoms of, 661 
table of diagnostic symptoms of, 661, 662, 

663 

treatment of, 668 
periodic, 671 

permanent alternating, 671 
monocular, 671 
phenomena of vision in, 671 
results of tenotomy, 675 
spastic, 669 
sursumvergent, 670 


Strabismus, treatment of, 673 
varieties of, 670 
Streatfeild, 221 
Streptococci, in corneal ulcers, 309 
Striate keratitis, 338 
retinitis, 518 
Striped keratitis, 338 
Stroschein flask, 247, 250 
Strumous keratitis, 320 321 
ophthalmia, 272 
Strychnin in heterophoria, 6S0 
in ocular paralysis, 666, 668 
in optic-nerve atrophy, 547 
Strzeminski, 182, 267 
Stye, 166 

Style, lacrimal, 230 
Subacute conjunctivitis. 256 
Subconjunctival cysts, 242 
ecchymosis, 293 
hemorrhage, 293 
injections, 301, 455 
lipoma, 240 

Subhyaloid hemorrhage, 494 

sensations of light. See Photopsia. 
Subretmal cysticercus, 488 1 

echinococcus, 489 
Substantia propria, 30 
Suction operation for cataract, 460 
Sudamma, 179 
Suker, 351, 462 
Sulphate of copper, 262, 283 
Superficial punctate keratitis, 333 
scleritis, 361 

Superior oblique, paralysis of 662 
^ rectus, paralysis of, 662 
Suppuration after cataract extraction 455 
Suppurative chorioiditis, 429 
dacrvoeystitis, 226 
iritis, 385 
keratitis, 307 

Suprarenal capsule, extract of, 755 
Surface needling of cornea, 351 
Sursumduction, 109 
Sursumvergence, 109 
Suspensory ligament of lens 54 
Susskind, 222 
Sutphen, 525 
Swanzy, 319, 336, 496, 514 
Sweet, 154, 371 
method with x-rays, 154 
Sycosis tarsi, 185 

Symblepharon, 158, 190, 218, 293 295 
operations for Arlt’s, 298 
Harlan’s, 299 
Knapp’s, 298 
Teale’s, 298 
skin grafts in, 299 

transplantation of rabbit’s conjunctiva in, 
298 

treatment of, 298 

Sympathetic affections, conditions producing, 
594 


eye diseases, 594 
fibrinous uveitis, 599 

ganglion, superior cervical, excision of 586 
inflammation. See Sympathetic ophthalmi¬ 
tis. 

irritation, 594, 595 
causes of, 594 
diagnosis of, 596 
prognosis of, 597 
symptoms of, 595 
treatment of, 597 

nerve, changes in, in glaucoma, 565 
ophthalmitis. 458, 598 
bacteria theories of, 603 
causes of, 598 

ciliary-nerve theory of, 603 
combined theories of, 603 
enucleation in, 604 
exenteration (evisceration) in, 604 
following cataract extraction, 458 
immunity to, 613 
optic-nerve theory of, 603 
pathogenesis of, 602 
pathology of, 601 
period of latency in, 598 
prognosis of, 601 
prophylaxis of, 604 
symptoms of, 598 










818 


INDEX. 


Sympathetic ophthalmitis, toxin theories of, 603 
treatment of, 604 , 

papilloretinitis, 601 
Sympatheticectomy, 586 
Sympathizing eye, 594 
Synchysis corporis vitrei, 477 
etincelant, 477 
scintillans, 477 
sparkling, 477 
Syndectomy, 301 

Synechia, annular posterior, 387 
anterior, 309 
division of, 393 
posterior, 387 
Syphilis, 418, 509 
in chronic ophthalmoplegia, 666 
of conjunctiva, 291 
of eyelids, 173 
of lacrimal gland, 221 
Syphilitic arteritis of the retina, 501 
chorioidoretinitis, 426 
hemorrhagic retinitis, 501 * 

lesions of conjunctiva, 291 
perivasculitis of the retina, 501 
retinitis, 500, 501 
teeth, 323 

Syringomyelia, 744 
Syrup of iodid of iron, 274 
Szokalski, 305 
Szymanowski, 215 

Tabes dorsalis, 741 
Tagliacozzi, 215 
Talamon, 251 
Tansley, 197 
operation for ptosis, 197 
Tapetum, 39 
Tarsal plate, 26 
tumor, 181 
Tarsitis, 162 
Tarsorrhaphy, 188, 200 
operations, 200 
Tarsus. 26 

inflammation of, 162 
removal of, 299 

Tattooing, accidental, of skin, 167 
of cornea, 351, 359 
Tay, Waken, 424, 512 
chorioiditis of, 426 

Teale’s operation for symblepharon, 298 
Tear-stone, 223 
Teeth, notched, 323 
pegged, 323 
Teichopsia, 557 
Tendo oculi, 26 
Tenonitis, 632 
after tenotomy, 682 
Tenon’s capsule, 11 
advancement of, 685 
Tenotomy, 681 
accidents during, 682 
complete, 681 
complications after, 6S2 
graduated. 683 
in heterophoria, 683 

in convergent concomitant strabismus, 675 
in divergence excess, 681 
in heterophoria, 681 
in myopia, 716 
in strabismus, 681 
Tension, intra-ocular, 99, 562 
determination of, by manometer, 100 
effect of irritation of fifth nerve on, 562 
of mydriatics on, 132 
of sympathetic nerve on, 562 
examination of, 99 
in cataract, 446 
in detachment of retina, 523 
in glaucoma, 562 
normal intra-ocular, 562 
periodic variations of, in glaucoma, 572 
Tensor chorioidea, 38 
Tepljaschin, 173 
Terson, 359 

Test-types, Burchardt’s, 121 
Monoyer’s, 120 
Snellen’s, 118 
Wallace’s, 119 

Tests for simulated blindness, 151 
Tetany, 743 


Thalamus opticus, 41, 736 
Theobald, probes of, 229, 235 
Theodor, Duke Carl, 507' 

Therapeutic iridectomy, 398 
Thiersch, 211, 213, 217, 299 
method of skin-grafting, 217 
Thiosinamin, 351 
Third nerve, 17 
radiations of, 51 
recurrent paralysis of, 667 
Thomas, 496 

Thompson, J. H., 255, 283 
Thomsen’s disease, 744 
Thomson, 128 

Thrombosis of cavernous sinus, 636 
of central retinal artery, 498 
vein, 498 

of orbital vein, 498 
Tilley, 633 
Tinea tarsi, 185 
Tobacco amblyopia, 542 
Todd, 611 
Tonometers, 100 
Tonsure of the cornea, 301 
Toric lens, 690 
Tornatola, 4 
Torsion, 565 

Total prolapse of iris, 309 
staphyloma of cornea, 342 
Trachoma, 277 
acute, 279 
bodies, 277, 279 
canthoplasty in, 200, 201 
canthotomy in, 200 
chronic, 278 
coccus, 277 
complications of, 280 
conditions favoring, 278 
contagiousness of, 278 
copper in treatment of, 283 
corneal opacities after. 280 
definition of, 277 
diagnosis of, 281 
etiology of, 277 
excision in, 283, 299 
expression in, 283, 300 
follicles, 279 
follicular, 257 

forceps, Knapp’s roller, 300 
forms of, 278 

geographic limitations of, 278 
granular, 278 
grattage in, 283, 301 
iehtnyol in treatment of, 283 
iodic acid in, 283 
iodin in treatment of, 283 
jequirity in, 284 
microorganisms in, 277 
mixed, 280 
papillary, 278 
pathology of, 281 
periectomy in. 284, 301 
peritomy in, 301 
prognosis of, 282 
prophylaxis of, 282 
racial susceptibility to, 278 
sequelae of, 280 
silver in treatment of, 283 
strong bichlorid solutions in, 301 
treatment of, 282 
vegetable fungus in, 277 
Transfixion of the iris, 400 
Transplantation of skin without a pedicle, 
Transverse film of the cornea, 334 
Traumatic cataract, 445, 464 
irideremia, 395 
retinitis, 521 
Tremulous iris, 396 
Trephining of the cornea, 360 
Trial case, 732 
-frame, 120 

Trichiasis, 190, 201, 280 
after trachoma, 280 
operations for, 201 
treatment of, 201 
Trichosis carunculte, 296 
Tripier, 230 
Troncoso, 569, 570 
Tropacocain, 754 
Tropometer, 110 




INDEX. 


819 


Tropometer, use of. 111 
Trousseau, 359 
Truc, 131 

Tscherning, 66, 550 
Tubercular disease of conjunctiva, 289 
mass, large, 413 
meningitis, 740 
Tuberculin injections, 380 
Tuberculosis of chorioid, 412 
of conjunctiva, 289 
of cornea, 341 
of eyelids, 172 
of iris, 380 
of retina, 527 

Tumors, intra-ocular, 377, 404, 414, 482 
of brain, 508 
of caruncle, 296 
of cerebellum, 534 
of chorioid, 414 
of iris, 377 

of lacrimal gland, 221 
of optic nerve, 530 
of orbit, 618 

Tunica vasculosa lentis, 3 
Tweedy, 641 • 

Tylosis, 186 

Tyrrell, drilling operation of, 461, 600, 605 

Uhthoff, 303, 307, 504, 505, 555 
Ulcer, Jacob’s, 177 
of conjunctiva, 292 
of cornea, 308, 309 
rodent, 176, 177 
Ulcus cornea serpens, 311 
Ulrich, 554, 555 

Upper cul-de-sac, excision of, 299 
Uratic conjunctivitis, 276 
Uremic amaurosis, 552 
Uridrosis, 179 
Urticaria, 160 
Use of miotics, 134 
mydriaties, 131, 132 
Uveal tract, 33 
Uveite irienne, 390 
Uveitis, anterior, 364 
fibrinous, 599 
serosa, 599 

Vaccinia of conjunctiva, 284 
of eyelids, 184 
Vail, D. T., 539 
Validol, 558 
Valude, 131, 334 
Van Bambeke, 2 
Van Fleet, 197 
Van Gieson’s stain, 782 
Varicella of conjunctiva, 284 
of eyelids, 184 

Varicose veins of eyelids, 170 
Variola, 183, 276, 313 
Variolar conjunctivitis, 276 
ulcers of cornea, 313 
Vascular growths in iris, 380 
keratitis, 325 
systems of the eye, 90 
Vasculitis, 490 
Veasey, 177, 178, 252, 379 
Veins of eyelids, 2o 
of iris, 35 
of orbit, 21 
Venae vorticosse, 39 
in glaucoma, 567 
Venous pulsation, 59 
Veratrin ointment, 190 
Verdese, 307 
Vernal conjunctivitis, 260 
Verruca of eyelid, 168 
Verrucosities of optic-nerve head, 532 
Vertical meridian, 768 
Vertigo, 659 
Vesicular catarrh, 254 
Vincentiis, 225, 281, 291 
Virchow, 429 

Vision abnormalities of field of, 736 
binocular, 75 
clearness of, 81 
direct and indirect, 79 
field of, 77 

false projection of field of, in paralytic 
strabismus, 657 


Vision, field of, method of testing, 124 

Bjerrum’s method of ascertaining field 
of, 125 

color-field of, 78 
in glaucoma, 569 
in hysteric amblyopia, 558 
in optic-nerve atrophy, 545 
in retinal anesthesia, 527 
for colors, 78 

iridescent, in glaucoma, 567 
method of ascertaining field of, 124 
normal acuteness of, 118 
rods and cones in, 79 
testing acuteness of, 118 
Visual acuity, 6o 
testing of, 118 
amnesia, 739 
angle, 65, 119 
aphasia, 739 
area, 41 

diagrams showing, 42 
centre, 82 
field, 77 

hallucinations, 739 
line, 68 

rotation of eyeball around, 73, 656 
purple, 80 
radiations, 82 
rods and cones, 79 
sensations, duration of, 80 
tract, 735 
Vitiligo, 170 

Vitreous body or humor, anatomy of, 54 
animal parasites in, 478 
artificial, 611 

blood-vessel formation in, 479 
cholesterin in, 477 
coloboma of, 473 
corpuscles of, 54 
cysticercus of, 478, 487 
degeneration of, in myopia, 710 
detachment of, 480 
development of, 3 
diseases of, 473-480 
dust-like opacities of, 475 
entozoa in, 478 
examination of, 99 
fibrillse of, 54 
filaria sanguinis in, 478 
fluidity of, 477 
foreign bodies in, 480 
formation of new vessels in, 479 
hemorrhage into, 476 
hyaloid membrane of, 54 
inflammation of, 473 
loss of, 453 
membranes in, 480 
opacities of, 475 
causes of, 475 
in chorioiditis, 422 
treatment of, 476 
parasites in, 478 
prolapse of, 453 
purulent inflammation of, 474 
spontaneous hemorrhage into, 476 
spontaneous inflammation of, 474 
suppurative inflammation of. 474 
VOLKHANN, 301 
Von Ammon, 201, 206, 208, 367 
Von Graefe, 380, 436, 525, 584 
Von Hippel, 158, 360 
Von Holder, 649 

Von Kolliker, illustrations from, 2, 5 
Von Michel, 277, 324, 380, 498 
Vossius, 339 
Vrolik, 471 

Waoenmann, 324 
Wagner, 478, 505 
Wallace, test-type of, 119 
Walter, 522 

Walzberg, illustration from, 171 
Warburg’s tincture, 392 
Wardrop, 240 

Washing of eye specimens, 775 
Watch-glass in purulent conjunctivitis, 265 
Watson, 361 
Weber, 234, 307, 311 
Weeks, 252, 339, 508 
bacillus, 256 




820 


INDEX. 


Wegner, 562 
Wehrle, 312, 315 
Weichselbaum, 251 
Weidler, 230 
Weigert’s stain, 783 
Weinbaum, 578 
Wenzel, 461 

Wernicke’s pupillary symptom, 97, 739 
Wernke, 225 
Westcott, C. D., 305 
Westphal-Piltz reaction, 98 
White, 467 

Wicherkiewicz, 207, 330 

Wiener, 291 

WlLBRAND, 642, 643, 644 

Wilder’s operation for ptosis, 196 

Williams, 128 

Wilson, 484 

Winselmann, 525 

Wintersteiner, 482, 485 

Wolfe, 526 

Wolff, 199, 471 

Wolffberg, test-type of, 121 

WOLFNER, 330 

Wollenberg, 528 

WOOD, C. A., 379, 430 

W’OODS, H., 427 

WOOLHOUSE, 400 

Word-blindness, 739 

Worth, C., 674 

Wounds and injuries of chorioid, 433 
of ciliary body, 409 
of conjunctiva, 294 
of cornea, 351 
of crystalline lens, 471 
of eyeball, 370 
of eyelids, 293 
of iris, 394 


Wounds and injuries of optic nerve, 560 
of orbit, 646 
of retina, 521 
of sclera, 368 
Wright, R. A., 283 
WURDEMANN, 304 

Xanthelasma of the cornea, 341 
Xanthoma, 172 
Xanthopsia, 556, 559 
Xeroderma pigmentosum, 171 
Xeroform, 262 
Xerophthalmos, 288 
Xerosis, 280, 288 
bacillus, 269, 271 
epithelial, 288 
of conjunctiva, 288, 318 
parenchymatous, 28S 
Xerotic keratitis, 318 
X-rays in detecting foreign bodies, 153 
in epithelioma of eyelids, 177 
in granular conjunctivitis, 283 
in tuberculosis of conjunctiva, 290 

Yaws, 161 

Yellow ointment in blepharitis, 187 
oxid of mercury, 187, 274, 321 
spot, 42 

Young’s theory of color-perception, 551 

Zehender, 347 
Zeiss’s glands, 166 
Zellweger, 378 

Zentmayer, W., chapter contributed by, 654 
Ziegler, 555 
Ziem, 278 

Zonula of Zinn, anatomy of, 54 
Zonular opacity of the cornea, 334 











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WmWi 









